
Objective: The aim of this study was to examine whether there is a difference in the behavioural characteristics of community- and clinic-based children with attention-deficit hyperactivity disorder (ADHD) in Korea.
Method: The study included 75 community-based and 72 clinic-based subjects with ADHD. The parents of all the children completed the parent versions of the Child Behavior Checklist (CBCL).
Results: The community-based ADHD subjects scored significantly higher (P < 0.01) than clinic-based subjects in the Somatic Complaints and Delinquent Behaviour profiles of the CBCL. The community-based subjects with ADHD, combined subtype, showed significantly higher mean scores in the Somatic Complaints (P < 0.01) and Thought Problems (P < 0.05) profiles than the clinic-based subjects with ADHD, combined subtype.
Conclusion: These findings suggest the possibility of an increased incidence of behavioural or emotional problems in community-based ADHD subjects when compared with clinic-based subjects in Korea.
(Can J Psychiatry 2007;52:61-65)
Information on funding and support and author affiliations appears at the end of the article.
Clinical Implications
* There is a possibility that community-based ADHD subjects show more psychiatric problems than clinic-based subjects in developing countries.
* The population-based samples of ADHD in Korea might be prone to an increased incidence of internalizing problems due to the underdetection of ADHD symptoms and a lack of adequate support from the community.
* Clinicians should consider the possibility of higher levels of associated psychopathology in population-based subjects with ADHD, compared with clinic-based ADHD subjects, in developing nations.
Limitations
* The sample size of subjects with ADHD was relatively small.
* The subjects might not be representative of all the children with ADHD in Korea.
Key Words: attention-deficit hyperactivity disorder, Child Behavior Checklist, community
Abbreviations used in this article
ADHD attention-deficit hyperactivity disorder
CBCL Child Behavior Checklist
K-SADS-PL Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version
SD standard deviation
ADHD is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsive behaviour that, according to the DSM-IV criteria, affects about 3% to 5% of school-age children.1 It has been suggested that clinic-based ADHD subjects tend to show more psychiatric symptoms and impairment than community-based subjects.2 However, most of the ADHD literature is based on clinic samples of children, which has the limitation of not representing most children in the community.
In this study, we report the CBCL3 profiles of community- and clinic-based children with ADHD in Korea. The CBCL has been used in school and clinical settings and is known to be useful for identifying children with ADHD.4,5 The aim of this study is to determine whether there is a difference in behavioural characteristics between these 2 groups.
Methods
Subjects
This study included 75 community-based subjects with ADHD and 72 outpatients with ADHD attending the child and adolescent psychiatry clinic of Seoul National University Hospital in Korea. For the recruitment of the commuity-based sample, a total of 2438 elementary school students (1st- to 3rd-year levels) from Chuncheon and Gunsan (mid-sized cities in Korea) were selected with guidance from the schools' administrations. Prior to inclusion, informed consent was obtained from parents, and assent was obtained from the participating children. In the next phase, we selected 369 individuals (15.1%) as potential participants, which was in accordance with the procedures of a previous study.6 We asked the parents of these potential subjects to participate in the detailed assessment of their children and obtained agreement in 184 cases (49.9%). There were no significant differences in the demographic characteristics of the excluded and included subjects. Of the 184 children included in the study, 75 were diagnosed as having ADHD.
Assessments
The parents of all the children with ADHD completed the parent versions of the CBCL.3 Following the CBCL's completion, the children were accompanied by their parents during a detailed psychiatric interview conducted by an experienced child and adolescent psychiatrist. The psychiatrist who conducted the interview was blinded to the CBCL results. The Korean version of the CBCL is known to have good validity and reliability.7 Diagnostic assessments of psychiatric disorders, including ADHD, were made with the K-SADS-PL according to the DSM-IV criteria.8 The Korean version of the K-SADS-PL was standardized by Kirn and colleagues,9 All the children with ADHD were drug-naive at the time of recruitment.
Statistical Analysis
Group differences in the clinical variables involving continuous data were computed with an independent 2-sample t test or 1-way analysis of covariance. Between-group comparisons involving categorical data were assessed using the chi-square test or Fisher's exact test. The significance level was set at P= 0.05 (2-tailed).
Results
Demographic and Clinical Characteristics
The demographic and clinical characteristics of the ADHD subjects are presented in Table 1. The mean age of the community-based children with ADHD was 7.97 years, SD 0.80 years, which was significantly different (P < 0.001) from that of the clinic-based subjects, who had a mean age of 9.33 years, SD 2.39 years. There were no significant differences in the percentages of the ADHD subtypes or comorbid disorders between the 2 groups.
Comparison of the CBCL Results Between Community and Clinic-Based Subjects With ADHD
Compared with the clinic-based subjects with ADHD, community-based subjects had significantly higher mean scores for the Somatic Complaints and Delinquent Behaviour profiles (Table 2) on the CBCL (P < 0.01).
The mean CBCL scores with regard to the Somatic Complaints and Thought Problems profiles were significantly higher (P < 0.01 and P < 0.05, respectively) in the community-based children (aged 8.23 years, SD 0.66 years, n = 40) than in the clinic-based children with ADHD combined subtype (aged 9.16 years, SD 2.73 years, n = 32). There were no significant differences in the CBCL results between the community- and clinic-based subjects with ADHD, inattentive type (data not shown).
Discussion
According to the CBCL results in this study, the community-based subjects with ADHD showed an increased incidence of behavioural or emotional problems, compared with the clinic-based subjects. These results were contrary to our expectations, since it was previously reported that clinic-based samples of ADHD patients tend to have more psychiatric problems than population-based samples.2 The findings of this study are meaningful because the possible influence on the study populations of clinical characteristics (for example, ADHD subtypes and comorbidity) as confounding factors has been removed.
The results of DSM-IV field trials and subsequent work have suggested that children with ADHD, combined subtype, display more externalizing behaviour problems than children with other subtypes, whereas subjects with ADHD, inattentive subtype, exhibit less disruptive behaviour comorbidity than those with other subtypes.10-12 However, there is currently no clear consensus on the association of ADHD subtypes and other forms of psychopathology. Further studies to identify differences in the behavioural characteristics between the community- and clinic-based subjects with ADHD will be required; in addition to including a greater number of participants, future studies should also consider the associated psychopathology of ADHD subtypes.
It is worth noting that the results of this study may have been affected by other factors associated with the sociocultural characteristics of the samples. It has been reported that, in comparison with other cultures, Korean parents are less sensitive to their children's emotional states such as depression and anxiety; rather, they tend to focus mainly on behavioural problems, such as aggressive and delinquent behaviours.13 The higher incidence of somatization problems that was found in the community-based subjects with ADHD in this study may reflect a correlate of other internalizing disorders in the affected children. Previous studies have reported that somatization is frequent in Korean patients with depression and may be a prominent part of the depressive symptomatology.14,15 It is a possible that population-based ADHD samples in Korea might have an increased incidence of internalizing problems owing to an insufficient understanding of ADHD symptoms, underdetection, and a lack of appropriate support or intervention from the community.
An increased incidence of depressive equivalents in our study's community-based ADHD subjects suggests that clinicians should consider the possibility of a higher level of associated psychopathology, compared with clinic-based ADHD subjects, when evaluating population-based ADHD samples in developing nations. However, the results of this study should be interpreted with caution, since the AnxiousDepressed profile of the CBCL was not elevated in the community-based ADHD subjects and the psychopathology was only expressed in depressive equivalents.
It is also noteworthy that, in Korea, there has historically been a lack of understanding of child mental health or child psychiatric disorders, and nationally supported community mental health services for children were only initiated in 2002. Although the country does not have problems with regard to ethnic-based inequities in mental health care,16 financial obstacles, as in other developing countries, still make access to health care difficult.
The results of this study suggest the possibility that community-based children with ADHD have an increased incidence of behavioural or emotional problems when compared with clinic-based children in Korea.
Funding and Support
This article received no funding and no support.
[Reference]
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[Reference]
R�sum� : Comparaison des profils de la Liste de comportement pour les enfants entre des enfants souffrant de trouble d'hyperactivit� avec d�ficit de l'attention en milieu communautaire et clinique, en Cor�e
Objectif : Cette �tude visait � examiner s'il y a une diff�rence dans les caract�ristiques de comportement entre des enfants souffrant de trouble d'hyperactivit� avec d�ficit de l'attention (THADA) en milieu communautaire et clinique, en Cor�e.
M�thode : L'�tude comprenait 75 sujets souffrant du THADA en milieu communautaire et 72 sujets souffrant du THADA en milieu clinique. Les parents de tous les enfants ont rempli les versions pour parents de la Liste de comportement pour les enfants (LCPE).
R�sultats : Les sujets souffrant du THADA en milieu communautaire ont eu des scores significativement plus �lev�s (P < 0,01) que les sujets en milieu clinique en ce qui concerne les plaintes somatiques et les profils de comportement d�linquant de la LCPE. Les sujets souffrant d'un sous-type combin� du THADA en milieu communautaire pr�sentaient des scores moyens significativement plus �lev�s dans les plaintes somatiques (P < 0,01) et les profils de perturbation de la pens�e (P < 0,05) que les sujets souffrant d'un sous-type combin� du THADA en milieu clinique.
Conclusion : Ces r�sultats sugg�rent la possibilit� d'une incidence accrue de probl�mes comportementaux-�motionnels chez les sujets souffrant du THADA en milieu communautaire, lorsqu'on les compare aux sujets en milieu clinique, en Cor�e.
[Author Affiliation]
Cheon-seok Suh, MD1, Jae-won Kim, MD2, Han-ik Yoo, MD3, Jun-won Hwang, MD4, Boong-nyun Kim, MD4, Min-sup Shin, PhD4, Soo-churl Cho, MD4
[Author Affiliation]
Manuscript received May 2006, revised, and accepted September 2006.
1 Staff Physician, Seoul Child Study Center, Seoul, Korea.
2 Clinical Instructor, Department of Child and Adolescent Psychiatry,
College of Medicine, Seoul National University Hospital, Seoul, Korea.
3 Professor, Department of Child and Adolescent Psychiatry, Asan Medical
Center, Seoul, Korea.
4 Professor, Department of Child and Adolescent Psychiatry, College of
Medicine, Seoul National University Hospital, Seoul, Korea.
Address for correspondence: Dr Jae-won Kim, Department of Child and Adolescent Psychiatry, College of Medicine, Seoul National University Hospital, 28 Yongon-Dong, Chongno-Gu, Seoul, Korea; adore412@paran.com