Hello, I am Kim Poong-nyeon from the Department of Child and Adolescent Psychiatry at Seoul National University Hospital. Today, I would like to talk to parents about attention deficit hyperactivity disorder, commonly known as ADHD. I believe this is an important topic that parents should be aware of. 

Attention deficit, or in other words, the attention aspect is one part of the condition, while the second part is hyperactivity, which refers to excessive movement. When looking at these two issues, parents and students can quickly recognize that a child is facing difficulties, especially when hyperactivity and impulsivity are present. This often leads to children visiting the hospital for diagnosis during their first year of elementary school or even in kindergarten. However, children who only exhibit attention deficit may go unnoticed until the first or second grade of elementary school.

Many problems start to emerge during the upper grades of elementary school, particularly regarding children's task performance and achievement levels. If the diagnosis is delayed, it can affect the effectiveness of treatment and may also lead to damage to self-esteem or difficulties in development. This can result in a poorer prognosis, as reported in various studies. It is important to understand that ADHD is not solely characterized by children who are distracted, talkative, noisy, or hyperactive. It is beneficial to recognize this opportunity. The diagnosis is not based solely on whether attention problems exist; rather, if attention issues are present, the specific characteristics of those problems are described in detail within the diagnostic criteria. Out of the nine diagnostic criteria, at least six must be met, and at the same time, the manifestations of these characteristics should be clearly evident.

In order to diagnose ADHD, it must be confirmed that it causes serious issues in academic performance, peer relationships, and parent-child relationships, which can hinder the child's development. Additionally, children who have both attention deficit and hyperactivity issues must meet certain criteria. Specifically, they should have 5 to 6 out of 9 items related to attention deficit and 5 to 6 out of 9 items related to hyperactivity and impulsivity. This means that approximately 14 out of 18 criteria must be satisfied. Only then can we confirm that there are significant issues with attention and hyperactivity. It is also important to remember a few key points beyond the diagnostic criteria. First, this is not a problem that arises suddenly; there are often difficulties present from the early stages of the child's development.

There are many cases, especially starting from the age of four, where self-regulation issues arise early. In particular, children who exhibit hyperactivity and impulsivity tend to struggle with self-regulation starting around four months of age. Children aged between 72 to 84 months, during their developmental process, often show improvement in self-regulation. However, the issue with ADHD is that this improvement does not occur. They continue to experience hyperactive behavior, difficulty controlling impulses, and challenges in maintaining attention. This leads to various behavioral characteristics and functional deficits. Understanding these processes as a whole is crucial for diagnosis, and I want to emphasize this point. Secondly, nowadays, evidence is considered very important. Therefore, the behavioral skills of parents or teachers alone do not solve everything. When diagnosing, it is advisable to conduct neuropsychological assessments whenever possible.

I recommend that you evaluate at least one important aspect for children, such as combat management function tests or attention assessments. It is important to neuropsychologically confirm that there are distinct deficits in the range of attention or impulsivity in children of the same age compared to healthy children. Of course, this is not the entirety of a diagnosis, but it can serve as a diagnostic aid. 

The third aspect we are currently attempting is a collaborative effort between Seoul National University Hospital and several other university hospitals. We are working on objectively assessing indicators related to brain development, such as the development and functional growth of the frontal lobe, as well as the development of synaptic neural circuits related to the frontal lobe. These efforts also assist in diagnosis based on brain morphology. 

Parents often have their own standards.

Because of this, there are quite a few parents who are sensitive about their children's behavior observations, especially when their children are not even 48 months old and are seen as misbehaving in kindergarten. Some parents come to the theater with this concern, but I believe that at that age, misbehavior should not be diagnosed as ADHD. It is normal for children to have immature self-regulation abilities, behavioral control, and overall executive function development at 48 months. I would recommend that parents observe their children at least until 72 months, but I have, on rare occasions, diagnosed a child around 60 months. In that case, the developmental impairment was significant. For example, the child would hit and push peers and exhibit many destructive behaviors, leading to being rejected by three different daycare centers. After more than a year and a half of this accumulation, I realized that...

You're a bad child, a bad child, and while saying things like that, they express very negative feelings about themselves. Their low self-esteem is clearly visible. In such situations, we can still expect some development of self-regulation abilities, but I have thought that providing treatment might actually be more beneficial for the child's development. This has crossed my mind a few times. 

Regarding elementary school-aged children, from first to sixth grade, research shows that about 12 out of 100 children may be affected. There are about twice as many boys as girls. It's important to keep in mind that girls often exhibit attention deficit traits and may be diagnosed later. I believe we should pay more attention to the difficulty in early detection moving forward. 

There are genetic factors involved; this is true for all neurodevelopmental issues. ADHD tends to be more pronounced in this regard. Overall, considering all these factors...

About 70% of cases are believed to be due to genetic factors. This is a probabilistic matter. It's a mistake to think simply that if a parent has ADHD, the child will have it too. Even if both parents are perfectly fine, their child can still have ADHD. There are many cases where it appears randomly in the genetic manufacturing process. Therefore, I hope parents do not think that they have passed on any problems to their child. At the same time, environmental factors are important. The experiences that children have in their growing environment are also significant. Recently, we have been focusing on environmental substances. The modern buildings surrounding our children, as well as the food they eat, the clothes they wear, and the school supplies they use, can create an unfavorable environment. There are several substances known as environmental hormones that can be harmful.

Now, if we look at the representative examples, there are three substances mentioned: phthalates, bisphenol A, and PFCs. All three of these are commonly found in items that our children frequently use, such as baby bottles, pencil cases, erasers, and backpacks. Currently, regulations are being actively implemented, but there are still many instances where school supplies with high concentrations of phthalates are detected and disposed of, as the country skips over these issues. It seems that prevention cannot solely rely on the individual efforts of parents. The government needs to impose restrictions, control, and provide guidelines from the very beginning of plastic manufacturing. Fortunately, guidelines for these three substances have been established since 2010. When the concentration of phthalates increases, issues related to children's attention and impulsivity tend to rise almost linearly.

When considering the professional factors, there are about half, and when combined with environmental factors, ADHD issues arise. We can control the environmental factors, and I believe we should raise our voices to ensure we can definitely manage and adjust those aspects. Regarding the prefrontal cortex, there are three key points to remember. The first is the prefrontal area, which is primarily responsible for working memory and executive functions, making it the most crucial element. The second is the area just below and inside the brain that handles planning and execution through motivation. Although it is also part of the prefrontal cortex, it relates to motivation for planning and execution. Lastly, there is the area related to attention shifting, which allows for multitasking and the ability to divide attention as needed. These three areas are essential parts of our children's brains.

In development, it's important to understand the areas related to attention problems. One of the things children struggle with the most is that their reward function doesn't work well. So what does an appropriate reward function mean? It means that as they develop according to their age, initially, they tend to want to quickly consume what is right in front of them. We like to achieve immediate satisfaction; this is what we call short-term reward, and they remain at that stage. However, as children grow, they learn to hold off on immediate gratification, understanding that if they wait, they can obtain more later. This is when they start receiving education or training to help them delay gratification in order to gain more rewards. This ability to delay gratification is what children with ADHD find most challenging. Essentially, remember that there are two main circuits in children's brains: the reward circuit and the executive function circuit.

It becomes possible to identify which circuits cause ADHD problems for our children. This relates to diagnostic criteria and issues of inattention. The attention span is short; this is quite subjective, but among groups of children with similar cognitive functions of the same age, significant differences can be clearly observed. In fact, while parents may find it difficult to determine if their child has a short or long attention span, teachers, who observe around 20 to 30 children at a time, can often identify two or three who have particularly short attention spans. Therefore, the diagnostic criteria hold significance. Parents have also noted that their children struggle to complete tasks. Typically, when tasks are assigned to our children, they are tailored to their age and cognitive abilities. If a child cannot complete these tasks, it suggests that there may be difficulties in maintaining attention.

There is a phenomenon called daydreaming. Children spend a lot of time zoning out. While zoning out is a necessary activity for giving our brains a rest, it can become problematic if it lasts too long. Even during class, if a child is lost in thought and zoning out, and when asked a question, responds with something completely unrelated or gives an irrelevant reaction, that’s when you should genuinely start to worry. Additionally, when there are stimuli, they can easily become distracted. Most children will turn their attention to interesting stimuli, but these kids can be easily distracted by meaningless sounds. They might hear a sound and immediately wonder, What is that? causing their attention to drift. It’s fine if just one characteristic appears, but if multiple traits consistently show up together, then it might indicate that this child’s attention is somewhat lower than their peers. In that case, it’s better to be concerned.

If this continues until around 72 to 84 months, it would be better to receive a proper diagnosis through evaluation. Hyperactivity and impulsivity tend to manifest relatively easily, as these patterns are quite noticeable. If a child consistently shows high levels of activity, and if by around 72 months there hasn’t been significant improvement, then it is truly concerning. If you feel that help is needed, it would be wise to seek assistance. However, the absence of these signs, as mentioned earlier, can be problematic. In such cases, attention deficit type, quiet ADHD often gets discovered late. When observing the activity levels of these children, I previously mentioned daydreaming. In addition to daydreaming, these children tend to appear somewhat lethargic and may struggle to complete tasks due to difficulties in maintaining focus.

If a child is easily distracted, has low academic performance, or receives poor evaluation scores, it may be worth considering whether they have attention deficit issues or if they are quiet and withdrawn. I believe it is meaningful to have them evaluated in such cases. There are also children who experience anxiety issues, and some may face frustrations in peer relationships or suffer from repetitive criticism in parent-child relationships, which can significantly lower their self-esteem and lead to feelings of depression. When emotional problems accompany attention issues, the attention problems tend to worsen. Therefore, addressing both the emotional issues and the attention problems together is crucial. In clinical practice, it seems very important to treat these issues simultaneously. The second type of issue involves escalating conflicts with parents. The child may refuse simple instructions from parents and exhibit oppositional behavior against what the parents desire.

To add a bit more, there are cases where aggressive words or aggressive behavior accompany this. It is essential for parents to receive education regarding the parent-child relationship, and I strongly recommend that children undergo medication treatment for their impulsivity. In the past, I used to think differently. When I started my fellowship, my teachers often mentioned that the age of children and adolescents is quite low. When you observe them, they often talk about being amazed, and I believed that too. The reason for the change is not anything other than the fact that long-term follow-up studies have started to emerge. Research has shown that among elementary school-aged children diagnosed with ADHD, studies have followed them into their early twenties and even recently into their forties. While not all of them maintain the diagnosis as adults, about two-thirds of those diagnosed in elementary school continue to receive the same diagnosis during adolescence.

Diagnosed with ADHD in their first year, some individuals still receive the diagnosis into their early twenties. This raises the need for new treatments for adults. One important aspect, I believe, is parent education. Parents need to understand ADHD well, including the difficulties with executive function and reward circuitry. They should be able to suggest activities and provide tasks that are appropriately tailored to their child's level. Parent education that can assist with this is extremely important. Additionally, medication treatment should be combined with it. The methods to enhance attention, improve executive function, and normalize the reward circuitry are, in my view, primarily through medication. Cognitive behavioral therapy and social skills training can certainly help, but treatment without medication or social skills training without medication is not sufficient.

Training can only have a minor impact on executive function circuits, reward circuits, and attention regulation abilities. As children reach an age where they can manage themselves, behavioral therapy becomes really important. They need to learn to manage their time, manage tasks, set plans, and create appropriate relationships with those around them. Cognitive-behavioral therapy is extremely important in this process. 

One of the main concerns is growth issues. Since Strattera has been introduced, children with growth problems can use this medication, which eliminates those concerns. Currently, it is one of the most commonly used medications, so the extent of growth issues has been a significant worry. Research from abroad shows studies ranging from 5 to 8 years. When we look at these studies comprehensively, it is clear that initially, it can cause a decrease in appetite.

In the early stages, if unemployment persists, there is a delay in growth. However, after that, about two-thirds of the children show a significant reduction in the intensity of appetite suppression. Approximately one-third of the children who continue to experience vision problems are advised to change their medication. Therefore, one could say that around 70% of the children, even if they initially experience some unemployment after starting treatment with Stabilan, can often regain their original appetite after about 100 to 120 days of maintenance therapy. This means that serious weight issues do not persist. Looking at it over a one-year period, if one becomes complacent and continues this treatment, I believe those children will face actual risk related to middle problems. This is because this is not a state of dopamine deficiency. When dopamine is excessively administered to children whose reward circuits are functioning healthily, it can lead to problems for those children.

Dopamine induction occurs, which creates a higher demand for dopamine. Therefore, I believe that after discontinuing the medication, the expectations for dopamine increase, leading to a higher risk of secondary issues. Parents often worry that their child will not be able to stop the medication. Many studies suggest that after about two to three years of medication treatment, it is advisable to plan for discontinuation, and there are quite a few children who succeed in this. As they approach adolescence, when children stop using medication after a certain period of treatment, their attention issues and executive function problems tend to improve, resulting in many cases where they no longer need the medication. The next point is the concern that stopping the medication will lead to the same problems returning, that it will be all for nothing. However, that is not the case; the brain's plasticity allows for recovery.

When the effects of medication, the successful experiences that children have, and cognitive-behavioral self-regulation training developed through relationships with parents come together, the actual regulatory functions and the abilities that children can develop on their own improve. It is important to remember that children with ADHD can also experience healthy development; it is not only healthy children who develop. The brains of children with ADHD also develop. However, because their development is often delayed and the effects of that development appear later, it is necessary to provide medication and behavioral therapy to mitigate various disadvantages. It is absolutely not true that the brains of children with ADHD do not develop. It is good to keep this in mind, and after about two years of stable treatment, when medication is discontinued, about one in three children may have the best chance of being able to stop taking medication. Please remember this.

Arirang, I would like to emphasize the importance of having sufficient treatment for attention regulation and overall performance enhancement over a significant period. Children who have had enough experiences with this type of treatment tend to maintain their self-esteem and improve their motivation, which leads to a favorable period for attention regulation during adolescence. On the other hand, those who have not experienced treatment lack successful experiences, which can lead to a negative perception of themselves and a gradual decrease in motivation. As a result, even when the opportunity to improve attention regulation arises, they may continue to remain in a state of insufficient recovery. Many people support this assertion. 

I would also like to mention the importance of the relationship between parents and their children. When the environment is distracting and children struggle to focus, teachers...

Many times, children are criticized for not performing tasks well, clashing with friends, and being self-centered. As a result, they tend to receive much more negative feedback than positive feedback while interacting with others outside. This can lead to an increase in self-criticism and negative thoughts about themselves. It is important for parents to be aware that such situations can arise. Parents should focus on how to help their child, who has a much higher level of negative perceptions, feel a sense of pride and develop positive expectations, believing that they can do well. I would like to emphasize this point. There are two methods to achieve this. One is to teach the child a skill or a method.

It teaches ways to succeed, but that's not easy. This is what mothers desperately want, and we also have a strong desire to help children achieve that as soon as possible. However, it's clear that medication alone does not lead to immediate functional recovery. Relationships do not suddenly improve, and children do not suddenly receive a lot of praise. What is certain is that once the treatment effects accumulate over time, children will receive more positive feedback and will be recognized more. They will be in a position to receive a lot of praise and expectations from their teachers. The problem lies in the time it takes to get there. During the recovery process and treatment, parents need to support the children until they improve. It cannot be resolved simply by teaching skills or methods; it needs to be done with genuine encouragement. Parents should simply praise them. Does that make sense?

It simply becomes praise. It's something they can do when you adjust your perspective. For example, when a mother is cleaning and wiping the desk, and her arm hurts, she might say, Could you wipe this for me? At that moment, she should give a lot of praise, saying, Thank you so much for helping me! My arm was hurting, but I think it’s getting better now. Children can sense when you're overdoing it, so you shouldn't exaggerate too much. Just a little exaggeration to match their perspective is good. Even the things that you think are obvious should be recognized and accepted actively. I hope mothers can show this kind of positive reinforcement for their children. I truly believe that this kind of positive behavior is like a refreshing rain in the midst of a drought for children. It helps them bloom again, regain their color, and grow their roots. Just by doing this, mothers can provide a healthy foundation for their children's self-esteem.

You have fulfilled your role. In my view, the second aspect is coaching. Providing feedback with genuine praise while aligning with the child's perspective helps reinforce positive behaviors. Coaching involves gradually raising expectations and showing the child that they can achieve certain goals, while also encouraging them to implement the methods shared.

Children with ADHD are likely to possess abilities that exceed our understanding. In cases of autism spectrum disorders, such as those on the submersion spectrum, the percentage is relatively low, around 1% to 10%. However, I believe that children with ADHD have a high potential for unique energy, activity levels, and creativity, which are often not found in the general population. I have seen many instances of this over the years, having worked with one child for about 10 to 15 years.

As I observe, there are cases where a child who struggled in elementary school goes on to university, creates a startup with a fantastic idea, and achieves success. It's remarkable to see the resilience and execution skills they demonstrate in overcoming various challenges along the way. Therefore, I strongly encourage you to pay close attention to the strengths that our children possess. In reality, as clinicians, we have very limited opportunities to meet a child briefly in the hospital. Parents see their children every day, so it's essential to open another window in your perspective. What are their strengths? What makes them special? There are definitely unique qualities. Helping them improve in areas where they struggle is important, and that is part of our role. However, discovering and nurturing the strengths they already have is far more valuable for them.

You can play a role that helps others and creates a great opportunity for social contribution. So, please recognize the strengths of our ADHD kids; many of them possess these strengths beyond expectations.

[명의 시리즈 : ADHD] 1~4편 몰아보기. ADHD의 정의/진단/원인/증상/치료/경과_우리 아이 마음 해결사, 우아해!

대한소아청소년정신의학회 공식 유튜브 "우아해" 입니다.

"진짜" 우리 아이 마음 해결사, 우아해는
다양한 아동발달,심리, 정서 그리고 질환에 관한 정보를 전달하고자 합니다.
넘쳐나는 정보 속에서 혼란스러운 부모님들을 위해
근거 있는 "진짜" 정보를 제공해서 
마음이 힘든 아동과 보호자가 없어지는 그날까지,
우리 아이 마음 해결사가 꾸준히 노력하겠습니다.

감사합니다.


대한소아청소년정신의학회 홍보이사 한덕현
대한소아청소년정신의학회   이사장  천근아

2024년 홍보위원 유튜브 팀
유튜브 팀장 : 박소영
팀원 : 고민수, 김병욱, 조성우, 정재오



[명의 시리즈 : ADHD] 1~4편 몰아보기. ADHD의 정의/진단/원인/증상/치료/경과_우리 아이 마음 해결사, 우아해!

[명의 시리즈 : ADHD] 1~4편 몰아보기. ADHD의 정의/진단/원인/증상/치료/경과_우리 아이 마음 해결사, 우아해!

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