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1 Continuing Education Column Treatment of Attention- Deficit Hyperactivity Disorder Young Key Kim, MD Dong Ho Song, MD Department of Psychiatry Institute of Behavioral Science in Medicine, Yonsei University College of Medicine E - mail : dhsong@yuhs.ac J Korean Med Assoc 2009; 52(5): Abstract This article presents the knowledges regarding the evaluation and the management of attention-deficit/hyperactivity disorder (ADHD). Probably the most important components to a comprehensive evaluation of patients with ADHD, are the clinical interview, the medical examination, and the completion and scoring of behavior rating scales. The treatments of ADHD are followings: pharmacologic treatment such as stimulants, atomoxetine, modafinil, and bupropionn, and non-pharmacologic treatment such as parental education/training and cognitivebehavioral treatment. Keywords: ADHD; Epidemiology; Evaluation; Treatment 489

2 Kim YK Song DH Table 1. Diagnostic criteria for Attention-Deficit / Hyperactivity Disorder (ADHD) A. Either (1) or (2): (1) Inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) Often has difficulty sustaining attention in tasks or play activities (c) Often does not seem to listen when spoken to directly (d) Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) Often has difficulty organizing tasks and activities (f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) Is often easily distracted by extraneous stimuli (i) Is often forgetful in daily activities (2) Hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) Often fidgets with hands or feet or squirms in seat (b) Often leaves seat in classroom or in other situations in which remaining seated is expected (c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) Often has difficulty playing or engaging in leisure activities quietly (e) Is often "on the go" or often acts as if "driven by a motor" (f) Often talks excessively Impulsivity (g) Often blurts out answers before questions have been completed (h) Often has difficulty awaiting turn (i) Often interrupts or intrudes on others (e.g., butts into conversations or games) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder). 490

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5 Treatment of Attention-Deficit Hyperactivity Disorder Table 2. Clinical and research scales for assessment and treatment response of ADHD Scales Notes Conners Parent Rating Scale-Revised, CPRS-R Self-report forms by parent and adolscent were developed Conners Teacher Rating Scale-Revised, CTRS-R Noh JS et al. developed Korean version of Conners Scale Child Behavior Checklist, CBCL Korean version of CBCL was developed by Oh KJ and Lee HR Child Behavior Checklist-Teacher Rating Form, CBCL-TRF Home Situation Questionnaire-Revised, HSQ-R HSQ-R consists of 14 items, rated 0~9 School Situations Questionnaire-Revised, SSQ-R Academic Performance Rating Scale, APRS APRS is 19- item scale, rated 1~6 and designed for assessment of academic performances and accuracies ADHD Rating Scale-IV for Parents and Teachers, ADHD RS-IV includes 18 items and Korean version was ADHD RS -IV standardized by So YK et al Inattention/Overactivity With Aggression (IOWA) IOWA CTRS was 10- item scale for assessing inattention, Conners Teacher Rating Scale, IOWA CTRS hyperactivity, and oppositional defiant problems Korean version was standardized by Shin MS et al Swanson, Nolan, and Pelham Rating Scale-IV, SNAP-IV SNAP-IV was 26- item scale 493

6 Kim YK Song DH Table 3. Available medications approved by food and drug administrations for ADHD in Korea Generic class Brand name Duration of How supplied Usual dosing Typical FDA Formulation activity Range starting Max/day and (hours) (mg/kg/day) dose mechnism Methylphenidate IR Methylpen, 3~4 5, 10 mg tablet 0.3~2.0 5 mg bid 60 mg Tablet of 50: Penid 10 racemic mixture D, I-threomethylphenidate Methylphenidate ER Metadate CD 8 10, 20, 30 mg 0.3~ mg qam 60 mg Two types of beads capsule; can be sprinkled give bimodal delivery (30% immediate and 70% delayed release) of 50 : 50 racemic mixture D, I-threomethylphenidate OROS - Concerta 12 18, 27 mg caplet 0.3~ mg qam 72 mg Osmotic pressure Methylphenidate system delivers 50:50 racemic mixture D,I-threomethylphenidate Atomoxetine Strattera 24 10, 18, 25, 40, mg/kg/day 1.4 mg Capsule of 60 mg capsule for 4 days; then /kg/day atomoxetine 1 mg/kg/days; or 100 mg then 1.2 mg /kg/day 494

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9 Treatment of Attention-Deficit Hyperactivity Disorder 11. Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46: Rowland AS, Umbach DM, Stallone L, Naftel AJ, Bohlig EM, Sandler DP. Prevalence of medication treatment for attention deficit-hyperactivity disorder among elementary school children in Johnston County, North Carolina. Am J Public Health 2002; 92: Barbaresi WJ, Katusic SK, Colligan RC et al. How common is attention deficit hyperactivity disorder? Incidence in a population-based birth cohort in Rochester, Minn. Arch Pediatr Adolesc Med 2002; 156: Woodruff TJ, Axelrad DA, Kyle AD, Nweke o, Miller GG, Hurley BJ. Trends in environmentally related childhood illnesses. Pediatrics 2004; 113: Dong Hyun Ahn, Hwayeon Kang, Bung-Nyun Kim, Ji Hoon Kim, Dongwon Shin, Su-Jin Yang, Hanik K. Yoo, Hee Jeong Yoo, Keun-Ah Cheon, Hyunju Hong. The Korean practice parameter for the treatment of attention deficit-hyperactivity disorder(i): Introduction, clinical features and course. J Kor Acad Child Adolesc Psychiatry 2007; 18: Kim JY, Ahn DH, Shin YJ. An epidemiological study of attention defeict-hyperactivity disorder and learning disabilities in a rural area. J Kor Neuropsychiatr Assoc 1999; 38: Kim JW, Park KH, Choe MJ. Screening for attention deficithyperactivity disorder in community mental services for children. J Kor Neuropsychiatr Assoc 20004; 43: Cho SC, Shin YO. Prevalence of disruptive behavior disorders. J Kor Acad Child Adolesc Psychiatry 1994; 5: Yang SJ, Cheong SS, Hong SD. Prevalence and correlates of attention deficit hyperactivity disorder: school-based mental health services in Seoul. J Kor Neuropsychiatr Assoc 2006; 45: Kang E Hong. Korean textbook of child psychiatry. Joonangcopy, 2005: Willcutt EG, Doyle AE, Nigg JT, Faraone SV, Pennington BF. Validity of the executive function theory of attention deficit hyperactivity disorder: a meta-analytic review. Biol Psychiatry 2005; 57: Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. Molecular genetics of attention deficit hyperactivity disorder. Biol Psychiatry 2005; 57: Castellanos RX, Lee PP, Sharp W, Jeffries NO, Greenstein DK, Clasen LS, Blumenthal JD, James RS, Ebens CL, Walter JM, Zijdenbos A, Evans AC, Giedd JN, Rapoport JL. Developmental trajectories of brain volume abnormalities in children and adolescents with attention deficit hyperactivity disorder. JAMA 2002; 288: American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed American Psychiatric Association. Washington DC. 15. Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention deficit hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. J Abnorm Psychol 2002; 111: Barkley RA. Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. Guilford Press. New York, Pliszka SR, Carlson DL, Swanson JM. ADHD with comorbid disorders: Clinical assessment and management New York: Guilford. 18. Faraone SV, Biederman J, Jetton JG, Tsuang MT. Attention deficit hyperactivity disorder and conduct disorder: longitudinal evidence for a familial subtype. Psychol Med 1997; 27:

10 Kim YK Song DH 19. Milberger S, Biederman J, Faraone SV, Chen L, Jones J, ADHD is associated with early initiation of cigarette smoking in children and adolescents. J Am Acad Child Adolesc Psychiatry 1997; 36: Biederman J, Wilens T, Mick E et al. Is ADHD a risk factor for psychoactive substance use disorders? Findings from a fouryear prospective follow-up study. J Am Acad Child Adolesc Psychiatry 1997; 36: Pliszka SR, Carlson CL, Swanson JM. ADHD with Comorbid Disorders: Clinical Assessment and Management New York: Guilford. 22. Biederman J, Newcorn J, Sprich S. Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. Am J Psychiatry 1991; 148: MTA Cooperative Group. Moderators and mediators of treatment response for children with attention deficit hyperactivity disorder: the MTA Study. Arch Gen Psychiatry 1999; 56: Spencer T, Biederman J, Caffey B, Geller D, Wilens T, Faraone S. The 4-year course of tic disorders in boys with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999; 56: Peterson BS, Pine DS, Cohen P, Brook JS. Prospective longitudinal study of tic, obsessive-compulsive, and attentiondeficit/hyperactivity disorderss in an epidemiological sample. J Am Acad Child Adolesc Psychiatry 2001; 40: Biederman J. Resolved: mania is mistaken for ADHD in prepubertal children, affirmative. J Am Acad Child Adolesc Psychiatry 1998; 37: Biederman J. Impact of comorbidity in adults with attentiondeficit/hyperactivity disorder. J Clin Psychiatry 2004; 65: Keun-Ah Cheon, Ji Hoon Kim, Hwayeon Kang, Bung-Nyun Kim, Dongwon Shin, Dong Hyun Ahn, Su-Jin Yang, Hanik K. Yoo, Hee Jeong Yoo, Hyunju Hong. The Korean practice parameter for the treatment of attention deficit-hyperactivity disorder(ii): Diagnosis and assessment. J Kor Acad Child Adolesc Psychiatry 2007; 18: Noh JS, Ko YJ, Seo DH, Sohn SH, Kim SJ, Kim YS. Korean standardization study of parent and teacher Conners Rating Scales. Scientific Proceeding Book for Spring Academy Meeting of Korean Academy of Child and Adolescent Psychiatry, So YK, Noh JS, Kim YS, Ko SG, Koh YJ. The reliability and validity of Korean parent and teacher ADHD rating scale. Kor J Neuropsychiatr Assoc 2002; 41: Oh KJ, Lee HR. Development of Korean version of Child Behavior Checklist (K-CBCL). Seoul: Korean Research Foundation Report, Hee Jeong Yoo, Su-Jin Yang, Dongwon Shin, Hwayeon Kang, Bung-Nyun Kim, Ji Hoon Kim, Dong Hyun Ahn, Hanik K. Yoo, Keun-Ah Cheon, Hyunju Hong. The Korean practice parameter for the treatment of attention deficit-hyperactivity disorder (III): Pharmacologic treatment. J Kor Acad Child Adolesc Psychiatry 2007; 18: Biederman J, Mick E, Surman C, Doyle R, Hammerness P, Harpold T et al. A randomized, placebo-controlled trial of OROS methylphenidate in adults with attention-deficit/ hyperacitivity disorder. Biol Psychiatry 2006; 59: Swanson J, Gupta S, Lam A, Shoulson I, Lerner M, Modi N, et al. Development of a new once-a day formulation of methylphenidate for the treatment of attentiondeficit/hyperactivity disorder. Proof-of concept and proof-of product studies. Arch Gen Psychiatry 2003; 60: Michelson D, Faries D, Wernicke J, kelsey D, Kendrick K, Sallee FR et al. Atomoxetine in the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled dose-response study. Pediatrics 2001; 8: e Michelson D, Allen AJ, Busner J, Casat C, Dunn D, Kratochvil C, Newcorn J, Sallee FR, Sangal RB, Saylor K, West S, Kelsey D, Wernicke J, Trapp NJ, Harder D. Once- daily atomoxetine treatment for children and adolescents with attention deficit hyperactivity disorder: a randomized, placebo-controlled study. Am J Psychiatry 2002; 159: Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen AJ, Kelsey D, Wernicke J, Dietrich A, Milton D. Atomoxetine in adults with ADHD: two randomized, placebocontrolled studies. Biol Psychiatry 2003; 53: Michelson D, Allen AJ, Busner J, Casat C, Dunn D, Kratochvil C, Newcorn J, Sallee FR, Sangal RB, Saylor K, West S, Kelsey D, Wernicke J, Trapp NJ, Harder D. Once-daily atomoxetine treatment for children and adolescents with attention deficit hyperactivity disorder: a randomized, placebo-controlled study. Am J Psychiatry 2002; 159: Kratochvil CJ, Newcorn JH, Arnold LE, Duesenberg D, Emslie GJ, Quintana H, Sarkis EH, Wagner KD, Gao H, Michelson D, Biederman J. Atomoxetine alone or combined with fluoxetine for treating ADHD with comorbid depressive or anxiety symptoms. J Am Acd Child Adolesc Psychiatry 2005; 44: Turner DC, Clark l, Dowson J, Robbins TW, Sahakian BJ. Modafinil improves cognition and response inhibition in adult attention deficit hyperactivity disorder. Biol Psychiatry 2004; 55: Greenhill LL, Biederman J, Boellner SW, Rugino TA, Sangal RB, Earl CQ, Jiang JG, Swanson JM. A randomized, doubleblind, placebo-controlled study of modafinil film-coated tablets in children and adolescents with attention-deficit/hyperacitivity disorder. J Am Aca Child Adolesc Psychiatry 2006; 45:

11 Treatment of Attention-Deficit Hyperactivity Disorder 42. Biederman J, Swanson JM, Wigal SB, Boellner SW, Earl CO, Lopez FA. A comparison of once-daily and divided doses of modafinil in children with attention-deficit/hyperacitivity disorder: a randomized, double-blind, and placebo-controlled study. J Clin Psychiatry 2006; 67: Kang E Hong. Korean textbook of child psychiatry. Joonangcopy 2005: Bung-Nyun Kim, Hanik K. Yoo, Hwayeon Kang, Ji Hoon Kim, Dongwon Shin, Dong Hyun Ahn, Su-Jin Yang, Hee Jeong Yoo, Keun-Ah Cheon, Hyunju Hong. The Korean practice parameter for the treatment of attention deficit-hyperactivity disorder(iv): Non-pharmacologic treatment. J Kor Acad Child Adolesc Psychiatry 2007; 18: Barkley RA, DuPaul GJ, McMurray MB. A comprehensive evaluation of attention deficit disorder with and without hyperactivity. J Consult Clin Psychol 1990; 58: Pelham WE, Wheeler T, Chronis A. Empirically supported psychosocial treatments for attention deficit/hyperacitiy disorder. J Clin Child Psychol 1998; 27: Pelham W, Waschbusch DA. Handbook of disruptive disorders. New York, Kluwer Academic/Plenum Abikoff H. Cognitive training in ADHD children: less to it than meets the eye. J Learn Disabil 1991; 24: Peer Reviewers Commentary 499

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상담학연구 ADHD- : ) 2) 3) 4) 5).,.,. MMPI, K-CBCL, KPR-C,. (Corresponding Author): / / 47 / Tel: / ADHD- : 1. 51 15.. 1) 2) 3) 4) 5).,.,. MMPI, K-CBCL, KPR-C,. (Corresponding Author): / / 47 / Tel: 031-416-7179 / E-mail: webhope@hanmail.net (Attention-deficit hyperactivity disorder, ADHD),, (DuPaul