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Korean Journal of Clinical Psychology 2018. Vol. 37, No. 4, 621-636 Review Article 2018 Korean Clinical Psychology Association https://doi.org/10.15842/kjcp.2018.37.4.013 eissn 2466-197X Evidence-Based Treatments of Attention Deficit Hyperactivity Disorder Sun-Mi Cho Department of Psychiatry & Behavioral Science, Ajou University School of Medicine, Suwon, Korea Attention-deficit/hyperactivity disorder (ADHD) is a common and impairing disorder affecting children, adolescents, and adults. Due to the increasing range of available options, selection and prioritization of treatments is becoming harder for clinicians. This review aims to provide a review of the literature on evidence-based psychotherapy treatments for ADHD supplemented by expert opinion on plausibility of symptoms improvement. In this paper, several meta-studies, which were conducted mainly in the United State and Korea were reviewed. As a result, behavioral parental training, behavioral classroom management, behavioral peer relationship intervention, and a combination of behavioral techniques were suggested as psychological treatment techniques. These techniques have been repeatedly proven to be effective in well-designed studies. In Korean studies, the effectiveness of non-behavioral techniques such as play therapy or art therapy has been demonstrated. These findings of this review are likely to be influenced by a number of factors such as research design, use of a control group, and measurement selection. Better designed follow-up studies are needed. Keywords: ADHD, behavioral parent training, behavioral classroom management, behavioral peer interventions 주의력결핍과잉행동장애 (ADHD) 의진단과특성 ADHD 의증상 ADHD 는초기아동기부터시작되어성인기까지생애전반에걸쳐 지속되는신경정신의학적장애이며, 삶의다양한영역 ( 학업, 또래 관계, 가족관계, 취업, 결혼, 건강, 금전관리, 운전등 ) 에심각한어 려움과손상을초래할수있다. ADHD 의주요증상은부주의, 과 잉행동, 충동성을들수있다 (Hales, 2008). 구체적으로살펴보면부주의 (inattention) 는수행중인과제나 주변상황에충분히주의를기울이지못하고, 사소한자극에도쉽 게주의가산만해지며, 계획을세우거나과제를지속하는데어려 움을초래하고, 해야할일을잊어버리는것과같은증상들을포함 한다. 주의유지능력이상황에따라극적으로달라지기도한다. 예 를들면 ADHD 증상을보이는아동은새로운상황이나일대일대 Correspondence to Sun-Mi Cho, Department of Psychiatry & Behavioral Science, Ajou University school of Medicine, 164 World cup-ro, Yeongtonggu, Suwon, Korea; E-mail: smcho@ajou.ac.kr Received Sep 27, 2018; Revised Nov 15, 2018; Accepted Nov 21, 2018 면상황, 피드백을자주받는상황과그렇지않은상황에서주의를기울이는정도가상당히다를수있다. 과잉행동 (hyperactivity) 은신체활동이과도하게많고, 모터가달린듯끊임없이움직이며, 이리저리뛰어다니거나착석이요구되는상황에서가만히앉아있지못하는것과같은행동을의미한다. 충동성 (impulsivity) 은심사숙고하지않은채의사결정을하고, 참을성이부족하거나타인을방해하고, 지시가끝나기도전에대답을하는행동으로나타난다. 충동성은장기적인결과를고려하지않은채단기적인보상에따라반응하게만들어결과적으로손해를겪을수있다. 초기에는 ADHD증상이아동청소년기에국한되어나타난다고알려졌으나 3,199명의성인을대상으로이루어진연구에따르면 4.4% 가 ADHD 진단준거를충족시키는것으로나타나성인기까지치료가필요하다는근거가증가하고있다 (Kessler et al., 2006). ADHD의진단은부모와아동을대상으로하는면담, 부모와교사에의한보고된표준화된검사등을통해이루어진다. 일차적으로는 ADHD에대한평가척도가가장좋은도구이며, 다른다른장애를광범위하게확인하는추가적인평가도도움이된다. 감별진단을요하는장애는품행장애 (Conduct Disorder) 와적대적반항성 621 www.kcp.or.kr

Cho 장애 (Oppositional Defiant Disorder), 간헐적폭발성장애 (Intermittent Explosive Disorder), 반응성애착장애 (Reactive Attachment Disorder), 학습장애 (Learning Disorder) 등다양한장애의진단가능성을고려해야한다 (Jensen, Martin, & Cantwell, 1997). ADHD의하위유형 DSM-IV에서는 ADHD를부주의, 과잉행동-충동성, 혼합형등세가지하위유형 (subtype) 으로나누었다. 그렇지만 DSM-5 에서는범주적접근보다는차원적접근방식을반영해서하위유형대신표현유형 (presentation type) 이라는용어를사용하였다. ADHD와파탄적행동장애 (Disruptive Behavior Disorder) 가신경발달장애 (Neurodevelopmental Disorder) 로바뀐것도 DSM-IV-TR이 DSM-5 로개정되는과정에서보인큰변화이다 (Pelham et al., 2005). 각하위유형은치료에대한반응과공존질환, 유전형에서차이를보인다는보고가많아하위유형이서로다른질환일가능성이높다는주장이반복해서제시되고있다 (Grizenko, Paci, & Joober, 2010; Grizenko, Shayan, Polotskaia, Ter-Stepanian, & Joober, 2008; Price et al., 2005). 2013). ADHD 유병률은연구에따라다른결과를보이지만연구방법론의차이를보정하였을때유병률의차이는크지않았다 (Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014). 86개의연구를메타분석한결과에따르면 DSM-IV의진단기준을충족시키는비율은 5.9 7.1% 이었다 (Willcutt, 2012). 또한미국과아프리카, 중동, 유럽등전세계에서출판된 303개의연구를메타회귀분석한결과에서 ADHD의유병률은 5.29% 로나타났는데방법론의영향을배제하면지역간차이는확인되지않았다. 이런결과는 ADHD의유병률이세계적으로유사한수준이라는점을반영하는것이다 (Polanczyk, Lima, Horta, Biederman, & Rohdey, 2007). ADHD 유병률에관한연구는국내에서도다수이루어졌다. 그결과초등학생은 1.99% 부터 13% 까지로유병률의편차가컸고, 중고등학생은 7% 정도의유병률을보였으며, 남녀비율은약 1.5 2:1 로나타났다 (Kim, Park, & Choi, 2004). 국내 ADHD의유병률은 DSM-V에서제시한내용과유사하지만지역이나도구에따라큰차이를보이고있어이를보정한연구가필요하다는주장이제기되고있다. ADHD의경과 DSM-IV에서 DSM-V로바뀌는과정에서성인 ADHD의진단기준을여섯개에서다섯개로줄인것은 ADHD 아동이성인이되면겉으로드러나는뚜렷한증상은감소된다는점을시사한다. 연구에따르면 ADHD로진단을받은아동중 44 80% 는성인기까지증상이지속되며 (Barkley & Fischer, 2010; Barkley, Murphy, & Fischer, 2010), 이들중소수는반사회적행동과약물남용과같은심각한문제를보인다 (Mannuzza & Klein, 2000; Rasmussen & Gillberg, 2000). ADHD로진단받은아동은성인이되면서 1/3 정도는증상이없어지지만 (Faraone, Biederman, & Mick, 2006), 나머지는여전히증상이지속되며, 이들중정신자극제치료 (psycho-stimulation medication) 나개인인지행동치료, 집단인지행동치료를받은집단은증상이줄어드는것으로나타났다 (Knouse, Cooper-Vince, Sprich, & Safren, 2008; Prince, 2006). ADHD의유병률 DSM-5에따르면 ADHD의유병률은아동의경우약 5%, 성인은약 2.5% 로보고하고있다. 남녀발생비율의차이는아동의경우약 2:1, 성인은 1.6:1로남자의발생률이높고, 부주의증상은남자보다여자에게서더많이나타난다 (American Psychiatry Association, ADHD의근거기반치료 : 해외 ADHD의일반적치료지침 ADHD는약물치료에대한반응이좋은질환으로알려져있으며, 약물치료와비약물치료가상호보완적인역할을한다. 적응문제가뚜렷한경우라면치료초기부터약물치료가필요하며, 대부분의경우약물치료와심리치료가병합되었을때효과는가장뚜렷한것으로알려져있다. 약물치료가행동치료에비해 ADHD 증상호전에효과적이라는사실이알려진이후약물치료를일차적인치료로권고하는것이일반적인추세이다 (Froehlich et al., 2007; Hunt, Arnsten, & Asbell, 1995). 그렇지만 ADHD의증상이학령기초반에나타나면서교육이나일상생활, 대인관계에미치는장기적인영향이크고, 부모를비롯한가족의부담등을고려할때약물치료만으로는충분하지못한경우가많아발달단계에맞는심리치료의병행은상당히중요하다 (Harpin, 2005). 또한흔하지는않지만약물치료가식욕저하및수면장해와같은부작용을초래할수도있고 (Correll & Carlson, 2006; Graham et al., 2011), 부모들이약물사용을꺼리거나단음식과같은식이문제가증상을유발한다는잘못된믿음때문에 (Dosreis et al., 2003) 약물치료적용이어려운상황도있다. ADHD 치료에서흥미로운점은약물치료와심리치료외의다 622 https://doi.org/10.15842/kjcp.2018.37.4.013

Evidence-based Treatments of ADHD 른개입방법을찾으려는시도가꾸준히있어왔다는것이다. 약물치료에대한심적부담과심리치료에드는비용혹은정신적문제가있는아이라는낙인에대한두려움으로기존의전통의학을보완하고통합하려는대체의학에대한관심이끊어지지않고있다. 현재까지밝혀진바에따르면 ADHD 증상에영향을미치는것으로알려진페인골드식이나설탕, 아연, 철은증상과의관련이확인되지않았고 (Akhondzadeh, Mohammadi, & Khademi, 2004; Kanarek, 1994; Konofal et al., 2008), 오메가 3의경우에만약하지만의미있는효과가입증되었다 (Johnson, Östlund, Fransson, Kadesjö, & Gillberg, 2009). 그렇지만식이요법은단일치료방법으로는적합하지않으며, 약물치료나심리치료를일차치료로선택한뒤추가적으로사용해볼수있다. 식이요법외에도작업기억력을증진시키는인지훈련, 뉴로피드백과같은방식이대안으로제시되고있으며, 대한소아청소년정신의학회에서도이에근거해비약물치료의권고안으로제시한바있다 (Shin et al., 2017). 그렇지만어떤메타연구에서도심리적개입의효과성이가장높은것으로나타나고있으며 (Sonuga-Barke et al., 2013), 단독약물치료와비교했을때약물치료와심리치료를병행하는것이더욱효과적이라는사실은오래전에입증되었다 (Jensen, 1999). 심리치료의효과성에대한메타분석 ADHD의심리치료에대한연구는 2000년무렵부터광범위하게이루어져왔으며, 효과성을입증하기위한다수의메타분석이시행되었다 (Chambless & Ollendick, 2001; Nigg, Lewis, Edinger, & Falk, 2012; Pelham & Fabiano, 2008). 대상자나회기수, 측정도구등이통일되지않았던초기단계의연구들은주로개입절차와측정도구의표준화에초점을맞추었던반면최근에는다수의연구가치료의효과성을입증하는데집중하고있다. 광범위한문헌을대상으로이루어진대표적인메타연구는 Evan 등 (2014) 에의해 2007 2013년동안출판된 4,669개의연구를분석한것이다 (Evans, Owens, & Bunford, 2014). APA 53분과아동청소년임상심리학회 (Society of Clinical Child & Adolescent Psychology) 는이분석결과를근거로 ADHD 치료권고안으로행동적접근방식 (Behavioral approaches) 과조직화개입 (organizational interventions) 방식을제시하였다. 여기에는행동적부모훈련 (Behavioral parent training, BPT), 행동적교실관리 (Behavioral classroom management, BCM), 행동적또래관계개입 (Behavioral peer interventions, BPI), 행동적기법의조합 (Combined behavior management interventions), 조직화훈련 (Organization training) 이포함되어있는데 행동적 이라는말은행동수정의원리에기반한다 는의미이다. Evans 등 (2014) 은각연구의피험자수와연령범위, 인종, 성차에대한자료와진단및측정도구에대한정보를정리하였으며, Nathan과 Gorman(2002) 이제시한기준에따라연구질의수준을결정했다. Evans를포함한오하이오대학심리학과의연구팀은최근까지도 ADHD 치료효과를검증한연구를지속해서업데이트하고있으며, 2014 년발표된논문에서제시된근거수준은 Table 1과같다 (Evans et al., 2014). ADHD 심리적개입및치료기법행동적부모훈련 (BPT) 행동적부모훈련 (BPT) 은부모관리훈련 (parent management training) 으로부르기도하며, 행동주의및사회학습이론의개념인조작적조건형성과기능적행동분석에토대를둔프로그램이다. 이프로그램의목적은 ADHD 증상을보이는학령전기혹은학령기아동의부모에게행동수정의기본개념을가르침으로써양육행동을효과적으로변화시키고자하는것이다 (Barkley, 1987). ADHD 아동은가정생활에있어서일반아동에비해규칙지키기나과제완수에어려움을겪기때문에아동을양육하고관리해야하는부모입장에서는감정을조절하며, 태도의일관성을유지하는데어려움을겪는다. 그렇지만부모가아동에게비일관적인태도를보이고, 지도감독을소홀하게할경우아동의문제행동이나정서문제는증가할수있기때문에적절한양육기술의활용은일반아동에비해서도훨씬중요하다고할수있다. Table 2에서볼수있듯이행동적부모훈련은효과성이입증된방식이다. 게다가한부모가정, 어머니가 ADHD 또는우울장애를겪는경우, 치료에대한접근성이떨어지는등특수한상황에서는부모훈련의중요성이더욱커진다. 따라서최근에는특수한상황에놓인부모훈련의효과를검증하는연구가다수이루어지고있다 (Rajwan, Chacko, Wymbs, & Wymbs, 2014). 부모훈련은 ADHD에수반되는증상뿐만아니라아니라이와관련된외현화증상과적대적반항장애, 품행장애등을목표로하여수행되기도한다 (Mabe, Turner, & Josephson, 2001). 2016 년수행된메타분석결과, 부모훈련은 0.51의효과크기 (effect size) 가확인되었고, 변인간의독립적관계를분석했을때부정적양육방식과통계적으로의미있는상관관계를보였다 (Rimestad, Lambek, Zacher Christiansen, & Hougaard, 2016). 행동적부모교육의핵심은긍정적강화를통해아동의행동을변화시키는것이다. 2017년대한소아청소년정신의학회에서는 < 주의력결핍과잉행동장애한국형치료권고안 > 을제시하면서행동적부모교육의예시를제 https://doi.org/10.15842/kjcp.2018.37.4.013 623

Cho Table 1. Measures and Results of Studies Included in Review Study Authors, Year (N, Age Range) Treatment Evaluated Behavior Management (BM) Behavioral Parent Training (BPT) Studies (Chacko et al., 2009) (120, 5 12) (Fabiano et al., 2009) (75, 6 12) (Fabiano et al., 2012) (55, 6 12) (McGrath et al., 2011) (72, 8 12) (Meyer & Kelley, 2007) (42, 11 14) (Van Den Hoofdakker et al., 2007) (94, 4 12) Outcome Measures ES BI vs. No Treatment ES BI vs. Alternative Treatment Clinical Significance 1. Waitlist (WL) Par DBD-ODD.44*.75* Reported % 2. BPT Par IRS-Parent.45*.50* 3. Enhanced BPT (STEPP) Par IRS-Family.59*.58* Par IRS-Overall.68*.52* DPICS-PP.60*.81* DPICS-NP.19*.68* PSI.29*.37* Combined BPTs vs. WL (M =.36) STEPP vs. BPT (M =.44) below clinical cutoff on each measures by group 1. BPT F Improve ratings NA.49* Not reported 2. Enhanced BPT (COACHES) 3. Waitlist F ECBI Intensity.55* NA Not reported 4. Enhanced BPT (COACHES) F DPICS Praise.54* F DPICS Negative Talk.57* 1. Waitlist Odds of successful outcome (defined as not meeting criteria for ADHD diagnosis at 120, 240, and 365 days of treatment) Odds ratios for diagnostic improvement:.2.16.2.18* Report % who no longer meet diagnostic criteria 2. BPT OR for ADHD- 120 days.2.74* 1. Waitlist (WL) Par HPC.5.55*.42 (PM> SM) Not reported 2. Self-Monitoring(SM).5.35* -.18 (SM> PM) 3. Parent-Monitoring(PM) Homework-% turned in.2.23* SM.2.35* PM 1. Routine Care (RC) Indiv. target behaviors.50* Not reported 2. BPT+RC Par CBCL Externalizing.06* Par CBCL Internalizing.36* Behavioral Classroom Management Studies (Fabiano et al., 2010b) (63, 5 12) 1. Business as Usual in SPED Classroom Rule Violations NA.20* Reported % (A. Y. Mikami, Griggs, Lerner, Emeh, Reuland, Jack, Anthony, et al., 2013) (137, 6.8 9.8) 2. BCM: Daily Report Card in SPED Tch DBD ODD/CD.43*.44* Tch APRS Success.37* Tch APRS Productivity.55* Tch Improvement Rating.69* below clinical cutoff on each measure by group 1. Active Control (COMET) Negative peer nominations.54* Reported % 2. BCM: MOSAIC Reciprocated friendships.71* within Sociometric ratings.52* typically developing Messages from peers.48* range on sociometric measures Behavioral Peer Intervention Studies (A. Mikami, Lerner, Griggs, McGrath, & Calhoun, 2010) (124, 6 10) 1. No Treatment 2. Parental Friendship Coaching Par SSRS.38* NA Reported % Par Quality of Play- Conflict.33* Par Quality of Play-.59* Tch SSRS.42* Tch DSAS Like & Accept.25* falling within normative range on the SSRS at pre and post-treatment (Continued to the next page) 624 https://doi.org/10.15842/kjcp.2018.37.4.013

Evidence-based Treatments of ADHD Table 1. Continued Study Authors, Year (N, Age Range) Treatment Evaluated Outcome Measures ES BI vs. No Treatment ES BI vs. Alternative Treatment Clinical Significance Combined BM Treatment Studies (Abikoff et al., 2013) (158, 8 11) 1. Waitlist Control Tch COSS.1.21* NA Report % no 2. PATHKO Par COSS.2.13* Tch APRS.82* Tch HPCL.1.51* Tch FES.54* Tch COSS Conflict.1.03* longer meeting criteria for organization, time management, and planning impairment (Langberg et al., 2010) 1. Community Control (CC) Par HPC-Inattention.39* -.02 Not reported 2. MED Par HPC-Total.39*.05* 3. BPT+BCM+Peer (BEH) (Pfiffner et al., 2007) (69, 7 11) (Power et al., 2012) (199, 2nd 6th grade) (Webster-Stratton, Reid, Beauchaine, & Psychology, 2011) (94, 4 6) 1. No treatment Control Par/Tch Inattention Count.18* NA Reported % 2. BPT+BCM+Peer (CLAS) Par/Tch Inattention Severity.19* Par/Tch SCT Scale.22* Par/Tch SSRS.11* Par/Tch COSS.17* Par/Tch Life Skills Knowledge.64* within the normative range for selective rating scales 1. Active control (CARE) Parent as Educator Scale NA.37* Not reported 2. BPT+BCM (FSS) Par PTIQ.29* Par HPC-Inattention.52* Par HPQ.34* Par PCRQ-Negative Discipline.59* 1. Waitlist M CBCL Externalizing.06* NA Not reported 2. BPT (Incredible Years)+Child group (Dinosaur School) M CBCL Aggression.04* M CBCL Attention.04* M CPRS-R ODD.11* M CPRS-R Inatten.07* M CPRS-R Hyper.13* M ECBI Intensity.22* M ECBI Problem.24* M Emotion Reg.22* M Social Comp.17* F CBCL Externalizing.06* F CRPS-R ODD.05* F CRPS-R Inatten.06* F CRPS-R Hyper.06* F ECBI Intensity.16* F ECBI Problem.16* F Emotion Reg.24* F Social Comp.12* Tch TRF Externalizing.04* Free Play DPICS Praise.12* DPICS Coaching.15* Task Time DPICS Negative Statements.06* DPICS Child Deviance.06* School Peer Observations COCA social Contact.08* (Continued to the next page) https://doi.org/10.15842/kjcp.2018.37.4.013 625

Cho Table 1. Continued Study Authors, Year (N, Age Range) Treatment Evaluated Outcome Measures ES BI vs. No Treatment ES BI vs. Alternative Treatment Clinical Significance Training Interventions Cognitive Training Studies (Beck, Hanson, 1. Waitlist control Par conners ADHD index.76* NA Reported % Puffenberger, 2. Working Memory Training Par Conners Inattention.79* meeting CS Benninger, & Par Conners Hyperactivity.36* change and Benninger, 2010) RCI on all Par Conners DSM-IV.1.49* (52, 7 17) measures Inatten. Par BRIEF Metacognition.91* Par BRIEF Working.85* Memory Par BRIEF Initiate.94* Par BRIEF Planning.92* Tch BRIEF Initiate.42* (Van der Oord, Ponsioen, Geurts, Brink, & Prins, 2014) (40, 8 12) Neurofeedback Training Studies (Gevensleben et al., 2009) (102, 8 12) (Abikoff et al., 2013) (158, 8 11) (Langberg et al., 2012) (47, 11 14) Combined Training Studies (Evans, Schultz, DeMars, & Davis, 2011) (49, 10 13) 1. Waitlist Par Inattention.25* NA Not reported 2. Executive Functioning Training Par Hyp/Imp.22* Par BRIEF Metacot.16* Par BRIEF Total.16* 3. Attention Skills Training Par ADHD Total NA.60* Not reported 4. Neurofeedback Trianing Par Inattention.57* Par Hyperactive/Impulsive.45* Par ODD.38* Par Delinquent/Aggression.37* Par SDQ Total.51* Par SDQ Hyperactivity.60* Tch ADHD Total.64* Tch Inattention.50* Tch SDQ Hyperactivity.48* 1. Waitlist Control Tch COSS.1.18* OST -.02 Report % no 2. PATHKO Par COSS.2.77* OST.63* (OST > PATHKO) 3. OST Child COSS.69* OST.22 Tch APRS.76* OST -.08 Tch APS.42* OST.23 Par HPCL.1.37* OST -.14 Par FES.47* OST.07 Par COSS Conflict.1.26* OST.22 longer meeting criteria for impairment in organization, time management and planning 1. Waitlist Control Par COSS Planning.1.05* NA Not reported 2. HOPS Program Par COSS Organization.88* Par COSS Materials Mgt.63* Par COSS Life Interference.69* Par COSS Family Conflict.79* Par HPC Homework.85* Complete Par HPC Materials Mgt.82* Par VADPRS Inattention.52* 1. Community Care Par DBD Hyp/Imp.90* NA Not reported 2. Challenging Horizons Tch IRS Academic.25* Programs (Continued to the next page) 626 https://doi.org/10.15842/kjcp.2018.37.4.013

Evidence-based Treatments of ADHD Table 1. Continued Study Authors, Year (N, Age Range) Treatment Evaluated Outcome Measures ES BI vs. No Treatment ES BI vs. Alternative Treatment Clinical Significance (Molina et al., 2008) (23, 6th 8th grade) 1. Community Care Par BASC Internalizing.47* NA Not reported 2. Challenging Horizons Adol BASC Delinquency.57* Programs Adol BASC School Maldadjust.79* Note. APRS = Academic Performance Rating Scale; BASC = Behavior Assessment Scale for Children; BCM = Behavioral Classroom Management; BDI= Beck Depression Inventory; BPT= Behavioral Parenting Training; Bracken= Bracken Basic Concepts Scale - Revised; CBT= Cognitive Behavioral Treatment; COSS = Children s Organizational Skills Scale; CPRS-R:S = Conners Parent Rating Scale-Revised: Short Form; CPRS-R-L = Conners Parent Rating Scales - Revised Long Form; CPS = Class-Classroom Performance Survey; CS = Clinically Significant; CTRS-R-L = Conners Teacher Rating Scales - Revised Long Form; DBD = Disruptive Behavior Disorders Rating Scale; DIBELS = Dy-Dynamic Indicators of Basic Early Literacy Skills; DPICS =Dyadic Parent-Child Interaction System; DPICSPP =Dyadic Parent-Child Interaction Coding System Positive Parenting; DPICSNP= Dyadic Parent-Child Interaction Coding System Negative Parenting; DSAS= Dishion Social Acceptance Scale; ECBI= Eyberg Child Behavior Inventory; ES = Effect sizes as reported by the study s authors; Cohen s d unless otherwise noted by a superscript; and positive ES indicates that the primary treatment being tested is superior; F= Father ratings; HPC= Ho-Homework Problem Checklist; HPQ= Homework Performance Questionnaire; IRS = Impairment Rating Scale; LA = Language Arts; M = Mother ratings; NS = Nonsignificant with insufficient data to calculate an effect size; OR = Odds ratio; Par = Parent; PCRQ = Parent Child Relationship Questionnaire; PSI = Parenting Stress Index; PTIQ = Parent Teacher Involvement Questionnaire; RCI = Reliable Change Index; SNAP = Swanson, Nolan, and Pelham ADHD Rating Scale; SPED = Special Education; SSRS = Social Skills Rating System; STP= Summer Treatment Program; Tch= Teacher; VADPRS= Vanderbilt ADHD Diagnostic Parent Rating Scale. Bold indicates that comparison is well-established treatment. 시하였으며, 구체적인내용은권고안에서제시하였다 (Shin et al., 2017; Yun Mi Shin, 2017). ADHD에대한부모교육은다양한모드를활용했을때효과가더큰것으로나타났다 (Jans et al., 2015). ADHD는생물학적취약성을가진질환이기때문에증상을가진아동의부모역시 ADHD 증상을보일수있다. 이같은경우부모의양육은더욱부적응적이며, 치료에대한아동은반응은그렇지않은집단에비해낮은것으로나타났다 (Babinski, Waxmonsky, Waschbusch, & Pelham Jr, 2015). 부모가 ADHD 증상을보일경우행동적부모훈련과어머니에대한약물치료를함께실시했을때더욱효과적이라는연구보고가있다 (Chronis-Tuscano, Wang, Strickland, Almirall, & Stein, 2016). 또한부모의반사회적특성이부모훈련의효과를감소시킬수도있기때문에행동적부모훈련과사회기술훈련이나작업기억력훈련등다른행동적치료기법을병행하는것도도움이된다는제안도있다 (Steeger, Gondoli, Gibson, & Morrissey, 2016). 이연구에서는부모훈련과작업기억력훈련을함께시행했을때, 각각의치료를단독으로시행했을때에비해 ADHD 증상의감소가더컸던 이르는반면다수의부모들이맞벌이로바쁜점을감안하면비디오를통한훈련은효율성을높이는데일조할수있다. 훈련내용을다양한형태로수정해서적용한연구도증가하고있다 (Abikoff et al., 2013). 적대적이고거부적인아동을자녀로둔부모를대상으로기존방식과 New Forest Parenting Program(NEFF) 을적용한집단과통제집단의결과를비교하였다. NEFF는 ADHD 증상이면에있는과정에초점을맞춘것이다 (Thompson et al., 2009). 연구자들은기존훈련방식에서는다루지않았던자기조절, 주의집중, 충동조절, 작업기억에주의를기울였다. 또한그동안치료효과측정에개입하지않았던교사의평정척도도포함시켰으며, 욕구충족의보류및과제집중정도를실험적기법으로확인하였다. 치료가끝난후 ADHD 및 ODD 증상에대한부모의평정치는치료전에비해유의미하게감소하였으나교사의평정및실험적결과에서는차이가확인되지않았다. 따라서증상이면의기전을다루는방식은뚜렷한효과가입증되지않아 Barkely 등에의해제안된고전적인기법은현재까지도가장효과가뚜렷한개입방법이라고하겠다 (Anastopoulos, DuPaul, & Barkley, 1991; Barkley, 2013). 것으로보고하였다 (Maleki, Mashhadi, Soltanifar, Moharreri, & Ghamanabad, 2014). 최근에는비디오시청을통해이루어진훈련이면대면형태의교육만큼효과적이라는연구결과가발표되었다 (Xie et al., 2013). 부모는비디오테이프를시청하면서행동적기법들을습득하였고, 이에기반해아동을훈육한결과는직접교육을통해훈련한집단과차이를보이지않았다. ADHD의유병률이전체아동의 5% 정도에 행동적교실관리 (BCM) 학교장면에서행동수정의원리를적용해 ADHD 아동에대해개입하였을경우다른방식에비해가장효과가큰것으로알려졌다. 교실관리방법에대해다양한권고안이제시되었으며, 일반적으로다음과같은원칙들이중요한것으로밝혀졌다 : 1) ADHD 아동들에게규칙이나지시를전달할때보통의아이들에비해명확하고 https://doi.org/10.15842/kjcp.2018.37.4.013 627

Cho Table 2. Effect Size of Target Outcome Variables according to ADHD Intervention (N = 362) Intervention types Target outcome categories n d± SD Q (ρ) U (ρ) 95% CI NFS Overall Overall 362 1.32± 0.02 1,953.87 ( <.001) 542.93 ( <.001) 1.21 1.43 2,027 Cognitive & behavioral control training Attention problems 72 1.59± 0.05 433.71 ( <.001) 140.01 ( <.001) 1.33 1.86 501 Cognitive & behavior problems 148 1.30± 0.04 814.55 ( <.001) 208.81 ( <.001) 1.12 1.47 813 Social skills problems 125 1.15± 0.04 542.47 ( <.001) 176.79 ( <.001) 0.98 1.32 595 Ego & emotional problems 10 2.31± 0.15 121.38 ( <.001) 14.29 ( <.001) 1.11 3.50 105 Parenting problem 7 1.04± 0.16 2.39 (.881) 42.20 ( <.001) 0.72 1.35 29 Overall 161 1.79± 0.04 1,498.21 ( <.001) 267.86 ( <.001) 1.57 2.00 1,276 Attention problems 39 1.92± 0.07 377.12 ( <.001) 75.59 ( <.001) 1.48 2.35 335 Cognitive & behavior problems 75 1.63± 0.05 605.00 ( <.001) 114.80 ( <.001) 1.33 1.93 537 Social skills problems 43 1.89± 0.09 429.81 ( <.001) 69.27 ( <.001) 1.44 2.33 362 Ego & emotional problems 2 4.28± 0.27 55.22 ( <.001) 2.30 (.129) -1.25 9.81 41 Parenting problems 2 0.93± 0.26 0.65 (.420) 12.65 ( <.001) 0.42 1.44 7 Social skills training Overall 98 0.97± 0.05 151.60 ( <.001) 292.23 ( <.001) 0.86 1.08 377 Attention problems 18 1.27± 0.11 30.43 (.023) 68.96 ( <.001) 0.97 1.56 96 Cognitive & behavior problems 24 1.13± 0.09 51.47 (.001) 62.77 ( <.001) 0.85 1.41 111 Social skills problems 52 0.83± 0.06 52.02 (.434) 192.46 ( <.001) 0.72 0.95 165 Ego & emotional problems 4 0.53± 0.22 0.88 (.830) 5.72 (.017) 0.10 0.96 7 Parents training Overall 50 0.66± 0.06 75.94 (.008) 67.98 ( <.001) 0.51 0.82 116 Attention problems 9 0.91± 0.16 8.19 (.415) 33.06 ( <.001) 0.60 1.22 32 Cognitive & behavior problems 23 0.55± 0.09 51.02 ( <.001) 15.51 ( <.001) 0.28 0.83 40 Social skills problems 12 0.52± 0.14 4.32 (.960) 14.32 ( <.001) 0.25 0.79 19 Ego & emotional problems 1 - - - - - Parenting problems 5 1.10± 0.20 1.46 (.834) 29.83 ( <.001) 0.71 1.50 23 Art therapy Overall 53 1.29± 0.07 143.84 ( <.001) 111.83 ( <.001) 1.05 1.53 289 Attention problems 6 1.52± 0.24 6.43 (.267) 30.13 ( <.001) 0.98 2.06 39 Cognitive & behavior problems 26 1.22± 0.10 59.45 ( <.001) 67.26 ( <.001) 0.93 1.52 133 Social skills problems 18 1.15± 0.13 37.38 (.003) 37.01 ( <.001) 0.78 1.52 85 Ego & emotional problems 3 5.87± 0.47 37.72 ( <.001) 2.97 (.085) -0.80 12.55 85 간단하고, 눈으로볼수있는형태로제시되어야한다. 2) ADHD 아동들은보통의아이들에비해빠르게결과를제시해주어야한다. 3) 특정행동에대한동기를강화하기위해행동의결과는보통아이들에비해자주제공해야한다. 4) 행동에대한결과는보통아이들보다강도가강하고, 강력해야한다 (Pfiffner, Barkley, & DuPaul, 2006). 행동적교실관리는치료효과에대한근거가잘확립된방식이다 (Pelham & Fabiano, 2008). Fabiano 등 (2010a) 은초등학교특수교육교실에서행동적교실관리프로그램의효과를평가하였다. 이들은교사들에대한자문 (Daily Report Card Consultation) 을지속하면서일일보고카드의효과를측정하였다. 그결과교실내에서아동들이규칙을어기는경우가줄어들었고, 적대적반항성장애와품행장애증상이줄어들었으며, 학업성취도가향상되었다. 다만 ADHD 아동의행동을변화시키기위해서는교실내에서프로그램을시행하는교사를따로고용하는것이필요하다는사실 이추가적으로확인되었다. 행동적교실관리에대한다른연구에서는교실내아동-교사의상호작용에새로운요인을추가하였다 (Mikami, Griggs, Lerner, Emeh, Reuland, Jack, & Anthony, 2013). 연구자들은유사한교실상황에서두가지방식의교실관리기법을비교하였다. 두가지방법모두가장흔한방식의방법에칭찬과개인적관심, 수용의표현과같은기법을추가하였다. 연구자들은이방법을 Making Socially Accepting Inclusive Classrooms(MOSAIC) 기법이라고불렀으며, 프로그램의효과는분명한것으로나타났다. MOSAIC 기법의목표는교사들의노력으로 ADHD 아동이또래집단내에서겪을수있는거절과사회적비난, 배제등을감소시키는것이다. 2주일동안훈련을시행한뒤 ADHD 아동의행동문제는뚜렷한감소를보이지않았다. 그렇지만또래관계에서겪는거절은줄어들었고, 친구들과의상호작용이증진되었으며, 이런효과는남자아이들에게더큰것으로나타났다. 이런연구를통해 ADHD 연구자들은아동 628 https://doi.org/10.15842/kjcp.2018.37.4.013

Evidence-based Treatments of ADHD 과교사의행동을새롭게조명하기시작하였다. 행동적교실관리기법은 1990년대초반에이미근거가분명한것으로확인되었지만연구는초등학교에서만이루어졌다는제한점이있다. 따라서청소년기와초기성인기로성장해가면서효과가지속되는지여부는잘알려지지않은상태이다. 또한행동적교실관리를하는경우약물치료없이증상이완화되었지만약물치료와같은일반적인개입을받거나불안장애가공존하는집단과큰차이를보이지않는다는연구도있었다 (Olfson, Marcus, Weissman, & Jensen, 2002). 결론적으로 ADHD 아동은심리사회적개입과약물치료를함께받을때가장치료효과가높다고할수있다 (Newcorn et al., 2001; Swanson et al., 2001). 행동적또래관계개입 (BPI) ADHD 아동들은또래집단에비해규칙을따르기어렵고, 차례를지키지못하며, 다른아동을방해하며, 결과를생각하지않은채행동하는경향때문에또래관계문제를보이는경우가잦다. 또래평정에따르면활동량이과도하게많거나지시에따르지않는행동, 공격적인행동은부정적인평가를받으며, 거부당하는경우가많다 (Erhardt & Hinshaw, 1994). 따라서행동수정이론에기반한또래관계개입방법이개발되었으며, 효과성이입증되었다. 또래관계개입은고전적인방식의사회기술훈련과 Summer Treatment Programs(STP)(Pelham et al., 2010) 와같은레크리에이션활동에서의행동적개입등두가지범주로나눌수있다. 행동적또래관계개입은의사소통, 협동, 참여, 동의와같은기술을적절히사용했을때강화를주는방식으로이루어진다. 대규모의연구에서집단간비교를한결과 STP는효과가분명한것으로나타났다 (Pelham & Fabiano, 2008). 훈련기간동안훈련자는행동의수반성 (contingency) 관리를통해특정상황에서의사회적기능을향상시킨다. 부모보고에따르면훈련이후아동의사회기술과놀이의질은향상되었으며, 교사들은훈련에참여한아이들이이전에비해또래들에게좀더호감을받고, 수용받는정도도상승했다고하였다. 또한연구자들은교사들이프로그램에개입했다는사실을알리지않은채부모에게질문지를체크하도록했는데그결과또래간상호작용을지켜보는동안긍정적인행동에대한촉진과, 부정적인행동에대한교정행동이증가하였고, 비난은감소하였다. 행동적기법의조합 (Combined behavior management interventions) Pelham과 Fabiano(2008) 는연구를통해행동적부모훈련과행동 적교실관리기법이단독으로도효과가있지만이들을조합해서사용해도어느정도효과를보인다고하였다. 이런주장에대한근거가축적되면서행동수정의조합은 ADHD의심리치료중네번째범주로포함되었다. 연구에따르면행동적부모훈련과행동적교실관리의조합은아무런개입도이루어지지않은집단과비교할때상당한효과를보였다 (Abikoff et al., 2013; Langberg et al., 2010; Webster-Stratton, Reid, & Beauchaine, 2011). 과제수행에대해개입방법을조합해서적용한뒤부모로하여금 ADHD 증상척도를실시하자다른방식의개입을실시한집단에비해의미있는정도로증상의점수가감소하였다. 행동적기법을조합하여적용한 DuPaul 등 (2013) 의연구는학령전기아동중 ADHD 가능성이높은아이들을대상으로이루어졌다. 이들은일반적인부모훈련과중다요소로구성된행동적개입을 20시간씩적용한뒤집단간차이를검증하였다. 부모교육프로그램에참여한지역사회의부모들이중다요소행동적개입에참여하였고, 아동들은행동문제와학업기술, 안전행동에초점을맞춘교육을받았다. 이들에게는효과적인부모교육에대한체계적인훈련프로그램이적용되었으며 (Dinkmeyer, Dinkmeyer Jr, & McKay, 1997), 연구에참여한모든참가자들이종속변수측정치에서의미있는향상을보였다. 이런결과는근거가뚜렷한개입방법을조합할경우단독개입에비해다양한영역에서향상을보인다는점을시사한다. 조직화훈련 (Organization training) 조직화훈련은 ADHD 아동들이학습을조직화하는데어려움을보인다는점에관심을가진연구자들이 지금하고있는 (on-going) 과제에초점을맞추는개입방법을고안한것이다. 방대한연구결과를분석한결과다음과같은두가지요소가효과가있는것으로밝혀졌다. 하나는조직화영역과대인관계영역, 학습영역에서필요한전략을배우는것이고, 다른하나는컴퓨터에서제시하는청각적, 시각적자극에집중하는훈련이다. 각회기는한번부터수백번까지의다양한횟수로구성되며, 각수행에대해피드백이주어졌다. 조직화훈련의효과는일상적인생활에서표적행동이얼마나향상되었는가를측정한결과로입증된다. 조직화훈련은대부분컴퓨터과제를통해작업기억과같은인지기능을훈련시키는것이며, 사용된자극이나임상가의상호작용이일상생활과연관되었을때가장강력한효과를보였다 (Tamm, Epstein, Peugh, Nakonezny, & Hughes, 2013). 반면컴퓨터에서의미없는소리나상징을제시하고집중하도록하는과제도있다. 이같 https://doi.org/10.15842/kjcp.2018.37.4.013 629

Cho 은훈련의특징은시행횟수가매우많다는것이며, 훈련의논리는일상과무관한자극의가치가낮다는것을인지시켜주의를덜기울이게하는것이다. 중요한과제목록이나일상의계획과같이일상생활과상관이매우높은자극을드문간격으로제시하는방식의훈련역시어느정도효과가있는것으로나타났다 (Mostofsky & Simmonds, 2008; Sprich, Safren, Finkelstein, Remmert, & Hammerness, 2016). 오락용디지털게임과같은방식이훈련에사용되기도하였다 (Bul et al., 2016). 연구에참여한 ADHD 아동들은게임집단과대기집단에무선적으로할당되었고, 10주이후집단간차이를측정하였다. 디지털게임은계획을수립하고, 시간을조절하며, 협동해야하는내용으로만들어졌다. 한회기는 62분이었고, 연구에참여한아동은일주일에세번씩이게임을하였다. 10주가지난후부모와교사에게질문지를실시한결과부모와교사모두훈련이전에비해시간조절능력과작업기억, 책임감이통제집단에비해상승했다고보고되었다. 연구결과를종합한결과지능수준이높은초등학생, 상대적으로교육수준이높은부모, 일주일에한두번회기에참여할정도로관심을가진부모가참여한경우상대적으로효과가높게나타나 (Abikoff et al., 2013; Langberg, Epstein, Becker, Girio-Herrera, & Vaughn, 2012) 훈련의효과는참가자의특징에따라다양한것으로결론내릴수있다. ADHD의근거기반치료 : 국내국내에서 ADHD 아동에대한심리치료효과를검증한메타연구는그리많이이루어지지않았으며, 모두같은연구팀에의해수행되었다 (Park, Park, & Hwang, 2015). 연구자들은국내데이터베이스인학술연구정보서비스 (Research Information Sharing Service [RISS]), 한국학술정보서비스 (Korean studies Information Service System [KISS]), 학술데이터베이스서비스 (DataBase Periodical Information Academic [DBpia]) 에서 1,298편의논문을찾아적합성을확인하는 4단계를거쳐최종 21편을분석대상으로선정하였다. 연구에서사용된 CBT 개입유형은사회기술훈련 (SST), 미술치료 (AT), 합리적정서적행동치료 (REBT), 자기통제훈련 (SCA), 문제해결기법 (PSA), 인지증진훈련 (CET), 중다양식치료 (MT), 인지모델링 (CM), Think Aloud 훈련 (TAT), 자기교시훈련 (SIT), 주의력향상훈련 (AIT), 컴퓨터훈련프로그램 (ccbt) 으로나타났다. 여러종류의중재를조합해서실시한연구도찾아볼수있다 (Seo & Park, 2010). 이연구의특징을살펴보면 ADHD 개입에효 과가입증되지않은미술치료나합리적정서적행동치료와같은기법이포함되었다는것이다. 국내논문중에는특히미술치료효과를검증한연구가많은데근거가확립되지않았을뿐아니라연구조건이잘통제되지않아 ADHD 증상을표적으로하는개입의효과를측정했다고보기는어렵다. 또한컴퓨터훈련프로그램을제외한나머지개입은과잉행동을줄이기위해사용되었다고하나대부분의행동적개입이과잉행동을직접줄이기보다는집중력과작업기억력을높이고, 또래관계기술및조직화기술을증진시키기위해사용된다는점으로볼때개입방법과표적증상이서로맞지않는다는제한점을갖는다. 국내메타연구의가장큰취약점은근거가가장잘확립된것으로확인된행동적부모훈련연구가한편도포함되지않았다는것이다. 이런결과는국내에서부모교육의중요성을간과하고있다는사실을보여준다. 또다른가능성은교육을시행한다하더라도구조화된매뉴얼을사용하고, 교육전과후의결과를비교하는방식으로이루어지지않을가능성을시사하는것같다. 더불어교실관리및또래관계에대한연구도찾아보기어려웠다. 소아정신과장애로분류된 ADHD의메타연구가간호학회주축으로이루어졌다는점도주목할필요가있다. ADHD의진단및치료에있어서심리평가와심리치료는임상심리학자를중심으로이루어지며, 진단및약물치료는정신과의사가시행한다. 따라서 ADHD의특징을잘이해하고그에맞는치료를선정하고실시할수있는전문가들이연구에대한관심은높지않을가능성도있다. ADHD 증상이의심되는아동을둔부모의경우소아정신과를방문해약물치료를받을수있으나병원의경우심리치료를병행할수있는전문가가부재한경우가많고, 소아정신과방문을꺼리는부모의경우근거기반중재기법을알지못하는비전문가를찾는비율이높아초래된결과일가능성도생각해볼수있다. 2010년에수행된메타분석 (Seo & Park, 2010) 은주제의범주를인지행동훈련, 사회기술훈련, 부모훈련, 예술치료로나누었으며, 근거가잘확립된부모훈련이포함되었다는점에서좀더균형을이룬결과를보여준다고할수있다. 이들은 1990년에서 2009년까지이루어진 200편의연구중 26편을선정하여자료를분석하였으며, 효과의크기는 1.32로큰편이었다. 가장효과적인개입방법은인지행동훈련이었으며, 예술치료와사회성훈련, 부모훈련의순으로효과가입증되었다. 그렇지만 2010년도연구 (Seo & Park, 2010) 와마찬가지로예술치료가효과적인개입방법으로나타났으며, 외국문헌과는달리부모훈련의효과가다른방법에비해상대적으로낮아그이유에대해논의할필요가있다. 추측하건대국내 ADHD 아동의경우개입 630 https://doi.org/10.15842/kjcp.2018.37.4.013

Evidence-based Treatments of ADHD 시기가외국에비해늦어이차적인정서문제가생겼거나부모-자녀관계의갈등이커져정서적개입이효과를보였을수있다. 또한각회기가구체적으로기술되어있는아동인지행동치료에비해부모들의다양한질문에답해야하는부모훈련을능숙하게실시할전문가가적은결과일수도있는것같다. 이같은결과를기반으로할때아동청소년심리치료자들은새로운지식체계를지속해서받아들이고, 효과가입증된기법을적극적으로적용하면서심리치료의주체로서활동할필요가있는것같다. ADHD의근거기반치료권고안및제언 ADHD는아동기정신장애중심리치료에대한근거기반기법이상당히잘이루어져있으며, 이런결과는오랜시간동안다수의연구를통해확증되었다. 이를근거로할때치료적권고안은다음과같다 (Table 3). 아동이 ADHD 증상으로치료가필요한지평가할때가정생활이나학교생활, 또래관계의적응문제가심하다면심리치료에대한계획을세우는것과함께우선약물치료를권유하는것이좋다. 미국심리학회에서도첫권고안으로 약물치료그리고 / 혹은심리치료 를제시하였으며, 두가지방법을병합했을때가장효과가있다고하였다. 또한똑같은기법의심리치료를적용해도약물치료가이루어지는아동에게서효과가더크다는점이이미입증되었고, 심지어어머니의 ADHD 치료를함께할때더욱효과가높은것으로나타났다. 따라서 ADHD 아동을치료하는임상심리학자는아동과함께가족전체의생물학적특징과가족역동, 훈육방식등심리사회생물학적측면을총체적으로평가할필요가있다. 약물치료의필요성에대해부모와합의가이루어지면그다음으 로아동의행동문제를표적으로한기능적분석및행동수정방식방식에대한계획을세워야한다. 행동수정기법에따른행동조절의플로우차트예시는 Figure 1에제시하였다 (Danforth, 2016). 최근들어새로운기법이나기존방식의새로운결합에대해연구가이루어지고있어주기적으로새로운연구를개관할필요는있으나이미매뉴얼화된행동적기법들이많기때문에치료방법을선택하는데크게고민할필요는없다. 가장효과가뚜렷한개입방법은행동적부모훈련이다. Kazdin의 < Parent management training: Treatment for oppositional, aggressive, and antisocial behavior in children and adolescents> (Kazdin, 2008) 는부모훈련의세부적인내용을기술한주요저서이며, 국내에서도여러권의번역서가있다 (Kazdin, 2007, 2014). 부모훈련은주 1회간격의 12회전후의횟수로구성되어있으며, 각각의회기에서는아동의문제행동을확인, 목록화하고그에대한대응행동을결정하고이를실천하는것으로이루어져있다. 아동의행동에대해사용할수있는개입기법들은 Table 4에제시되어있으며, ADHD에대한행동적기법을구체적으로찾아보기위해서는관련영역의웹사이트도도움이된다 ( 예를들면 www.russellbarkley.com). 근거가확립된기법을적용해최대의효과를얻기위해서는치료자의경험과역량이충분해야한다. 전문가들은프로그램실시경험이많지않은임상가는반드시슈퍼비전을받아야한다고말한다 (Schoenwald, Henggeler, Brondino, & Rowland, 2000). 같은매뉴얼을갖고프로그램을실시한다고해도아동개인의특징과부모의특징, 부모-자녀간관계, 훈육행동, 심지어약물에대한반응까지도모두통합할수있어야진행할수있기때문이다. 그렇지만국내의경우근거기반치료나평가기법, 슈퍼비전의중 Table 3. Summary Table of Levels of Evidence Level 1: Well-established Level 2: Probably Efficacious Level 3: Possibly Efficacious Behavioral Parent Training (P, E) Combined Training Interventions (CTI-1) Behavioral Parent Training (A) Behavioral Classroom Management (P, E) Neurofeedback Training (E) Level 4: Experimental Cognitive Training (E) Combined Training Interventions (CTI-2) Level 5: Questionable Efficacy Social Skills Training (E) Behavioral Peer Intervention (E) Behavioral Parent Training (M) Physical Activity (E) Omega 3/6 supplements (A) Organization Training (E, A) Combined Behavior Management Interventions (P, E) Note. P = Preschool; E = Elementary; A = Adolescents; CTI-1 = Combined training interventions that have extensive repetition of skills directly related to daily functioning; M = Modified versions of behavioral parent training for specific populations of parents with elementary-school-age children; CTI-1 = Combined training treatments with relevant skills and extensive practice and feedback; CTI-2 = Combined training treatments that include skills relevant to daily functioning but with limited practice and feedback and includes cognitive behavioral techniques and brief behavioral parent training. https://doi.org/10.15842/kjcp.2018.37.4.013 631

Cho Guided by Scientifically Minded Approach EBPCA Components Informant by Clinical Expertise Assessment Interventions Ongoing Monitoring Ongoing Monitoring Figure 1. Three primary and reciprocal elements of evidence-based clinical practice. 요성에대한인식이아직부족한편이다. 한연구에따르면정신건강영역의일부전문가들이근거기반평가와근거기반치료에대해부정적인견해를가진것으로나타났다 (Chad & Shin, 2014). 그중학교상담자의비율이가장높은것으로나타나고있어학교에서중요한역할을맡아야할전문가들의인식이향상될필요가있다. 이런결과로볼때아동정신건강영역에서큰역할을하는임상, 사회, 학교등포괄적인영역에걸친교육이필요할것으로보인다. 교사에의한행동적교실관리의영역은교육계와의연계없이는불가능하기때문에국내에서는심리학자들이개입하기어려운영역이다. 외국의경우 8주의여름프로그램을포함한 3개월의교실관리에대한연구가이루어졌고, 그결과는긍정적이었다 (Fabiano et al., 2010a). 그러나교실에서의행동적개입의효과를검증한국내연구는찾아볼수없었다. 미국의경우초등학교가지역사회내의정신건강센터와연계되어필요한경우평가와치료를의뢰하는데비해국내의경우이같은체계가미비해연구환경이취약한것같다. 종합하면아동기 ADHD의치료는약물적접근과비약물적접근의조합, 임상가및부모, 교사의참여등다양한여건이충족되어야효과적으로이루어질수있다. 이처럼다양한변수가존재하다보니근거기반치료의효과성을검증할때고려해야할변수가많고, 다양한영역의전문가가협력하여야한다. 국내에서는 ADHD 아동을돕기위한시스템이제대로구축되어있지않은점이치료 및연구에제한점이되고있어추후이런점이개선되어야할것같 다. 특히교실에서다양한행동개입을시행하고, 그결과를검증하 는연구가많이이루어져야할것같다. References Abikoff, H., Gallagher, R., Wells, K. C., Murray, D. W., Huang, L., Lu, F., & Petkova, E. (2013). Remediating organizational functioning in children with ADHD: Immediate and long-term effects from a randomized controlled trial. Journal of Consulting and Clinical Psychology, 81, 113. Akhondzadeh, S., Mohammadi, M. R., & Khademi, M. (2004). Zinc sulfate as an adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: A double blind and randomized trial. BMC Psychiatry, 4, 8-9. Anastopoulos, A. D., DuPaul, G. J., & Barkley, R. A. (1991). Stimulant medication and parent training therapies for attention deficit-hyperactivity disorder. Journal of Learning Disabilities, 24, 210-218. American Psychiatry Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5th ed). Arlington, V: American Psychiatric Pub. Babinski, D. E., Waxmonsky, J. G., Waschbusch, D. A., & Pelham, 632 https://doi.org/10.15842/kjcp.2018.37.4.013

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