Psychiatric Symptoms among Children withCongenital Heart DiseasePresented by: Hani HamedAssist. Prof. of PsychiatryActing Head, Psychiatry Department,Beni-Suef UniversitySupervisor of Psychiatry Department ,El-Fayoum UniversityMember of American Psychiatric AssociationAuthors: Hani Hamed*, Omnia Raafat**, Akmal Mostafa**, Mohamed Meabed***, Ola Dabbous*****Assist. Prof. of Psychiatry- Beni-Suef University, ** Assist. Prof. of Psychiatry- Cairo University, ***Prof. of PediatricsBeni Suef University, ****Lecturer of Pediatrics-National Institute of Laser Enhanced Sciences- Cairo UniversityAlex,May, 2013
Introduction The incidence of congenital Heart Diseases(CHD) was reported to be 8/1000 live borninfants. Annually, there are 400,000 deaths andhundred of thousands of children died dueto congenital heart diseases.
Introduction The prevalence of heart diseases in childrenin Egypt is not precisely estimated. Quality of Life (QOL) is an estimate ofremaining life free of impairment, disabilityor handicap.
Introduction When child develops cardiac disease theirconcepts of themselves and theirrelationships to their environments changeand, as a result, certain psychologicaladjustments are necessarily made. Children with congenital heart disease(CHD) have more medical fears, and morephysiological anxiety than normal peers.
Introduction Also, they have low self-esteem anddepression and are at particular risk for poorschool adjustment. Withdrawn aggressive behavior, somaticcomplaints, depression and anxiety are seenin children with congenital heart diseases.
Aim of the WorkPsychological implications are a significantpart of chronic illnesses and they can affectprognosis and outcome. The aim was:1- To study the presence of depressive andanxiety symptoms associated amongchildren with congenital heart disease.2- To study the neurocognitive deficits amongchildren with congenital heart disease.
Subjects and Methods Subjects: A case control study included thirty patients withdiagnosis of variable congenital heart disease “Cases”. They were operated for variable congenital heart diagnoses. The post-operative follow-up period of at least 2 years waschosen to exclude the effect of acute psychological distress. In addition, we only focused on a pediatric population andthus included patients who were on average younger than 12years at the time of assessment. They were attendants for clinical follow up.
Subjects and Methods Children were selected according to the inclusion andexclusion criteria two days per week from the outpatientpediatric cardiology clinic in Beni Suef University hospital(consecutive sampling). Another group of thirty children from gastrointestinaloutpatient pediatric clinic who were complaining from acutegastroenteritis were selected as “Controls”. Both samples were selected in the period from May 2011 toNovember 2011. Research ethical committee clearance was obtained and allenrolled children assents to participate were obtained inaddition to parents written consent approval.
Subjects and MethodsInclusion criteria:Both sexes.Age between 6-12 years.Acceptance to participate this study, by obtaining an informed consentfrom the legal guardian and child assent to participate.Children with average or below average IQExclusion criteria:Refusal to participate in this study by the legal guardian or child refusalto participate.Patients with chromosomal anomalies (syndromes) comorbid with thecongenital heart diseaseCurrent or history of other chronic medical condition.
Subjects and MethodsMethods:Subjects of the study were submitted to the following:I- Semi Structured Interview:Patients and controls were interviewed guided by a history takingsheet designed at the Department of Psychiatry, Beni SuefUniversity.It includes detailed developmental, family, educational and pasthistory.Also it includes a mental status examination.Psychiatric diagnosis if any had been done according to DSM-IVdiagnostic criteria.
Subjects and MethodsII – Wechsler Intelligence Scale for Children (WISC) (Ismaeil and meleka,1967) : It is one of the best-standardized and most widely usedintelligence tests in clinical practice today. Designed in 1939, theoriginal Wechsler Adult intelligence Scale WAIS has gone throughseveral revisions. This scale can be used for children ages 5 through15 years.This Scale consists of Verbal subtests, which include:- Knowledge, Comprehension, Arithmetic, SimilaritiesAnd also of Performance subtests, which include:- Picture Completion, Block Design, Picturearrangement, Object Assembly, Digit Symbol.
Subjects and MethodsIII- Childrens Depression Inventory (CDI): this scale was designedby Gharib (1988)The test was derived from Beck Depression Inventory for adults.It was translated into Arabic and was prepared for Egyptianculture use.The inventory consists of 27 groups of statements.Each one of the statement is having a score (0,1,2). The age of useof this test is 6-16 years old.
Subjects and MethodsIV- Anxiety Scale for Children: this scale was developed by EIBeblawy, (1987)The anxiety scale for children is the Arabic version of thechildren’s manifest anxiety scale (CMAS).It was prepared and translated into Arabic by Viola El Beblawy(1987) to be suitable for the Egyptian community.The scale consists of 42 items for measuring anxiety in childrenfor which the child answers by yes or no.
Subjects and MethodsV-Achenbachs Child Behavior Checklist: This instrument wasinitially designed by Achenbach (1991) to provide a reliablemeans of assessing the behavior problems and SocialCompetencies of children from 4 to 16 years old.It is one of the most extensively used parent reportquestionnaires that assess social competencies andbehavioral problems in children. It consists of 9 subscales,measuring variable behavioral disorders in children.Arabic version was done by El- -Defrawi and mahfouz, (1992). Theinstrument was initially translated into Arabic for use withEgyptian patients. After being modified in the course of thisreview, the instrument was back translated by a professionaltranslator.All scales were applied in Arabic language.
Subjects and MethodsStatistical Analysis:We computerized special data files, using Excel program 2010.Data were converted by using SPSS software program version17.0, analyzing characteristics of samples. Numbers andpercentages were calculated in regards to sex distribution,type of diagnosis. We compared the quantitative scores incases and controls by t-test and p values were calculated.Significance was set at 0.05. When the P value was less than0.05, the test was considered significant. Tables werepresented by using the same SPSS program.
ResultsPatient(n=30)Mean±SDControls(n=30)Mean±SDP-valueAge 9.2±2.9 10.6±3.2 0.223PatientsNo. (%)ControlsNo. (%)SexMale 17 (56.7) 16 (53.301Female 13 (43.3) 14 (46.7)Table (1) shows a non significant difference in the mean of age and sex betweenpatients and controls.1- Comparison between the patients and controls as regarding ageand sex:
ResultsDiagnosis Number PercentAdjustment disorder with depressedmood3 10Adjustment disorder with depressed andanxious mood4 13.4Conduct traits 1 3.3Oppositional Defiant Disorder 1 3.32- Distribution of psychiatric diagnosis among the patientgroup:Table (2) shows that, the majority of patients (23.4%) were with adjustmentdisorder.
ResultsPatient (n=30)Mean±SDControl (n=30)Mean±SDP-valueTotal 91.71±1.76 92.63±1.88 0.055Verbal total 92.90±1.94 93.19±2.01 0.572Performance total 92.03±1.99 92.03±2.07 1.00Knowledge 9.01±1.04 9.11±0.99 0.704Comprehension 7.23±.47 7.23±0.47 1.000Arithmetic 7.56±.49 7.46±0.57 0.469Similarities 8.39±1.99 8.45±1.99 0.907Picture Arrangement 7.29±.79 8.21±0.84 <0.001Object Assembly 7.47±.79 8.46±0.48 <0.001Picture Completion 7.37±.80 7.41±0.78 0.845Block Design 7.70±.82 7.74±0.83 0.852Digit Symbol 7.83±.92 8.83±0.99 <0.0013- Comparison between the patients and controls as regardingWechsler Intelligence Scale for Children (WISC):Table (3) shows a highly significant difference between patients and controls in picturearrangement, object assembly and digit symbol (performance subscales).
Cognitive Functioning Mahle et al., (2000) found a cognitive decline inchildren with heart disease and this may possiblybe explained by the fact that heart diseases wereassociated with risk factors that have a cumulativeadverse effect on cognitive functioning. For example, patients with more severe disease areat increased risk for congenital brain anomalies thatmay be associated with prenatal physiologicalevents and by chromosomal anomalies.
ResultsPatient(n=30)Mean±SDControl(n=30)Mean±SDP-valueAnxiety Scale forChildren28.7±6.3 24.6±4.8 0.006Childrens DepressionInventory (CDI)15.6±3.0 13.9±2.4 0.0194- Comparison between the patients and controls as regardingAnxiety Scale for Children and Childrens Depression Inventory(CDI):Table (4) shows that, there is a significant difference between patients and controlsregarding anxiety and depression scales.
Gupta et al., (2001) who found that, children with heartdiseases experience depression and anxiety due to post-operative stress, frequent hospitalization, daily medicationsand limitations imposed by the disease. In most of cases depression is under recognized, eitherbecause of health professionals consider it invetible orbecause children are not able to seek help. On contrary patients with complex heart disease and thosewho are at the end stage tend to express anxiety anddepression as the fear of the eminent death is quite strong. Another important factor in the development of anxiety anddepression is the familial reaction to the illness.Depression and Anxiety Symptoms
ResultsPatient (n=30)Mean±SDControl (n=30)Mean±SDP-valueAnxious depressed 8.3±3.2 5.6±3.7 0.004Withdrawal depressed 5.2±2.1 3.9±2.5 0.033Somatic complaints 6.5±2.7 5.2±2.5 0.058Social problems 5.7±2.5 4.5±2.3 0.058Thought problems 7.4±3.6 4.9±3.1 0.006Attention problems 5.7±2.3 4.8±2.2 0.127Rule breaking behavior 7.5±2.6 6.2±2.4 0.049Aggressive behavior 5.6±2.3 4.6±2.4 0.105Other problems 9.8±4.9 8.6±4.2 0.313Internalizing 64.3±9.7 56.8±7.5 0.001Externalizing 63.1±10.4 63.8±7.9 0.771Total score 66.5±11.4 60.6±8.7 0.0285- Comparison between patient and control as regards Achenbachs ChildBehavior Checklist, (Sub-scales, internalizing, externalizing and total):Table (5) shows a significant difference between patients and controls regarding Anxiousdepressed, withdrawal depressed, thought problems and role breaking behavior, internalizingand total score of Achenbachs Child Behavior Checklist
Internalizing, and ExternalizingBehavior Problems Lebovidge et al., (2003) who found that: childrenwith heart diseases display an increased risk ofoverall, internalizing, and to a lesser extentexternalizing behavior problem. These findings suggest that exposure to potentialrisk factors during the course of a patient’s life mayincrease the development of specificallyinternalizing behavior problems in older childrenwith heart diseases.
Conclusion There is high prevalence of behavioral, emotionaland cognitive problems in children with congenitalheart disease. A comprehensive approach in this field is essential,so that effective psychiatric interventions andguidance can be planned.
Limitations The sample size was small, so we could not deal withcongenital heart diseases separately or even divide intocyanotic versus non-cyanotic groups. Recommendation in further researches is to apply thepsychiatric assessment of the congenital heart diseases intocyanotic and a cyanotic subgroups and to enlarge the samplesize. Also, longitudinal studies starting from pre-operativepsychiatric assessment in a younger age must be done andcompared later on post-operatively.