Behavioral problems in adolescents with cardiac disease: an exploratory study in a pediatric cardiology outpatient clinic Dr Maria.

Behavioral problems in adolescents with cardiac disease: an exploratory study in a

pediatric cardiology outpatient clinic

mamaferrero@gmail.com

Dr Maria Marta Silva

Federal University of São Paulo - BrazilDivision of CardiologyPediatric Cardiology Unit of São Paulo Hospital

São Paulo Hospital is a university hospital that belongs to a public federal

institution that receives mostly low income patients. As a reference health

center, the patients that seek medical treatment are mostly severe cases

and come from every part of the country. Patients from middle and high

income prefer to pay for health care, going to private institutions.

SÃO PAULO HOSPITAL - BRAZIL

HEART DISEASES

Heart disorders are diseases that affect heart's structure and can impair its function. They may be of CONGENITAL or ACQUIRED nature.

HEART DISEASE: A CHRONIC DISEASE

In general, chronic diseases have profound impacts in patient`s quality of life.

Heart disease, as a chronic disease, can harm the DEVELOPMENT of children and adolescents and consequently trigger emotional and behavioral problems.

Heart diseases in adolescents and their therapeutic procedures may lead to problems in quality of life and lead to overprotection by parents, implicating in the TRANSITION from childhood to adulthood. In this sense, the skills to perform daily living tasks with their families may be affected.

PSYCHOLOGICAL ASPECTS OF HEART DISEASE

The literature suggests several predictors of behavioral problems in children who underwent CARDIAC SURGERY, among them are:

circulatory arrest the number of heart operations physical limitation low self-esteem increased fear of doctors maternal anxiety

PREDICTORS OF BEHAVIORAL PROBLEMS

IMPAIRMENT ON SOCIAL COMPETENCE

Through social contact, children and adolescents acquire skills, learn rules of coexistence, and accepted and valued behavior patterns of their culture. However, CHRONIC DISEASE can be A LIMITING FACTOR IN SOCIAL relationships with peers.

However, some studies have shown that patients with heart diseases may have internal RESOURCES to adaptively deal with their illness and to experience the situation resiliently.

RESILIENCE

The aim of the present study was to assess behavioral problems in adolescents with heart diseases treated at the Cardiology Outpatient Pediatric Clinic at Hospital São Paulo - Federal University of São Paulo (UNIFESP) comparing them to adolescents without heart disease, and to assess their parents` perception of such behavioral problems.

OBJECTIVE

MATERIAL AND METHODS

Study Group

376 participantsAge: 11-18

years

130 adolescents with heart diseases

56,9%: male43,1%: female

246 healthy adolescents 48,0%: male

52,0%: femalePrimary Caregivers

Control Group

130 parents

INSTRUMENTS

Semi–structured INTERVIEW YOUTH SELF-REPORT - YSR 11-18 (Achenbach, 1991) CHILD BEHAVIOR CHECKLIST – CBCL 4 - 18

(Achenbach, 1991)Self-report scale with 112 items for mental health screeningIntensity: score ranges (0, 1, 2)

ANALYSIS OF RESULTS

Total

Problems

Internalizing scale

Externalizing scale

Subscales

Reported behaviors

I – Withdrawn

II – Somatic ComplaintsIII – Anxiety/Depression

IV – Social ProblemsV – Thought Problems VI – Attention Problems

VII – Delinquent Behavior

VIII – Agressive Behavior

PROCEDURE

The study was approved by São Paulo Hospital – Federal University of São Paulo ETHICAL COMMITTEE for Medical Research in Human Beings before the number 0430/06.

The YOUTH SELF-REPORT was administered individually, while patients were waiting for doctor's appointment.

In the HEALTHY CONTROL GROUP, it was administered in school classrooms.

STATISCAL ANALYSIS

A databank was generated on Excel program and a statistical analysis was carried out using the Statistical Package for the Social Sciences SPSS 13.0

The nonparametric equality of two samples proportions test

The confidence interval or p-value had a level of significance of less than 0.05

RESULTS

Distribution of male adolescents with or without heart disease according to the YSR scales and

subscales

Intern

alizin

g

Extern

alizin

g

Total

Proble

ms

Withdra

wn

Somati

c Com

plaint

s

Anxio

us/Dep

ressed

Social

Prob

lems

Though

t Prob

lems

Attent

ion Pr

oblem

s

Delinq

uent

Behav

ior

Agres

sive B

ehavi

or 0

10

20

30

40

50

60

70

Study GroupControl Group

YSR subscalesYSR scales

*

**

*

%

*

Distribution of female adolescents with or without heart disease according to the YSR scales and

subscales

Intern

alizin

g

Exter

nalizi

ng

Total

Prob

lems

Withdra

wn

Somati

c Com

plai...

Anxio

us/Dep

ressed

Socia

l Prob

lems

Thou

ght P

roblem

s

Attenti

on Pr

oblem

s

Delinq

uent

Beha

v...

Agressi

ve Beh

avior

0

10

20

30

40

50

60

70

Study Group

Control Group

YSR subscalesYSR scales

*% *

Distribution of adolescents with or without heart disease according to gender for the YSR

scales and subscales

Intern

alizin

g

Extern

alizin

g

Total

Proble

ms

Withdra

wn

Somati

c Com

plaint

s

Anxio

us/Dep

ressed

Social

Prob

lems

Though

t Prob

lems

Attent

ion Pr

oblem

s

Delinqu

ent Beh

avior

Agres

sive B

ehavi

or 0

10

20

30

40

50

60

Male

Female

YSR scales YSR subscales

*

*%

Comparison between operated and non-operated male adolescents with heart disease according to the

YSR scales and subscales

Intern

alizing

Extern

alizin

g

Total

Proble

ms

Withdra

wn

Somati

c Com

plaint

s

Anxio

us/Dep

ressed

Social

Proble

ms

Though

t Prob

lems

Attent

ion Pr

oblem

s

Delinqu

ent Beh

avior

Agres

sive B

ehavio

r 0

10

20

30

40

50

60

Non-operated

Operated

YSR scales YSR subscales

%

Comparison between operated and non-operated female adolescents with heart disease according to the YSR

scales and subscales

0

10

20

30

40

50

60

Non-operated

Operated

YSR scales YSR subscales

%

Comparison between adolescents with congenital and acquired heart disease according to the YSR

scales and subscales

0

5

10

15

20

25

30

35

40

45

50

Acquired

Congenital

YSR scales YSR subscales

%

Comparison between adolescents with acyanotic or cyanotic heart disease according to the YSR scales

and subscales

Intern

alizing

Extern

alizin

g

Total

Proble

ms

Withdra

wn

Somati

c Com

plai...

Anxio

us/Dep

ressed

Social

Proble

ms

Though

t Prob

lems

Attent

ion Pr

oblem

s

Delinqu

ent Beh

av...

Agres

sive B

ehavi

or 0

10

20

30

40

50

60

Acyanotic

Cyanotic

YSR scales YSR subscales

%

Distribution of delayed or non-delayed schooling adolescents with heart disease according to the YSR

scales and subscales

Intern

alizing

Extern

alizin

g

Total

Proble

ms

Withdra

wn

Somati

c Com

plaint

s

Anxio

us/Dep

ressed

Social

Proble

ms

Though

t Prob

lems

Attent

ion Pr

oblem

s

Delinq

uent B

ehav

ior

Agres

sive B

ehavi

or 0

10

20

30

40

50

60

Not-delayed

Delayed

YSR scales YSR subscales

*

*%

*

*

Distribution of male adolescents with heart disease according to age groups classified for the YSR

scales and subscales

0

5

10

15

20

25

30

35

40

45

EarlyMiddleLate

YSR scales YSR subscales

**

%

Distribution of female adolescents with heart disease according to age groups classified for the YSR scales

and subscales

Intern

alizing

Extern

alizin

g

Total

Proble

ms

Withdra

wn

Somati

c Com

plaint

s

Anxio

us/Dep

ressed

Social

Proble

ms

Though

t Prob

lems

Attent

ion Pr

oblem

s

Delinq

uent B

ehavi

or

Agres

sive B

ehavio

r 0

10

20

30

40

50

60

70

80

Early

Middle

Late

*

YSR scales YSR subscales

**

*

* * *

%

Distribution of adolescents with heart disease compared with parents classified for the YSR and

CBCL scales and subscales

Intern

alizin

g

Extern

alizin

g

Total P

roblem

s

Withdra

wn

Somati

c Com

plaint

s

Anxio

us/Dep

ressed

Social

Prob

lems

Though

t Prob

lems

Attent

ion Pr

oblem

s

Delinq

uent

Behav

ior

Agres

sive B

ehavi

or 0

10

20

30

40

50

60

70

80

YSR Patients

CBCL Patients

YSR scales YSR subscales

**

**

*

%

Male patients showed significantly fewer Behavioral Problems compared to controls except in the Social Problems subscale.

Female patients did not differ significantly from female controls except in the Social Problems Subscale where patients were more problematic.

Among patients, females reported more Behavioral Problems than MALES in the Externalizing Scale and in the Attention Problems subscale.

CONCLUSIONS

The diagnostic groups did not differ. No difference was observed between operated and non-operated patients.

Female patients in late adolescence exhibited more problems than patients in middle and early adolescence in the Internalizing, Externalizing, Total Problems Scales, and the Delinquent Behaviour and Aggressive Behavior Subscales.

Female patients in middle adolescence displayed more problems when compared to late and early adolescence in the Internalizing and Total Problems Scales, and in the Withdrawn and Anxious/Depressed Subscales.

CONCLUSIONS

Male patients in early adolescence scored significantly higher in the Thought Problems and Attention Problems Subscales than did patients in middle and late adolescence.

Patients with delayed schooling displayed more behavioral problems in the Withdrawn and Anxious/Depressed Subscales.

Parents reported higher scores in comparison to patients in the Internalizing and Total Problems Scales and in the Withdrawn, Somatic Complaints and Thought Problems Subscales.

CONCLUSIONS

FINAL CONSIDERATIO

NS ADOLESCENTS with HEART DISEASE displayed fewer

behavioral problems than adolescents WITHOUT HEART DISEASE.

SOCIAL PROBLEMS were the most prominent behavioral problems in adolescents with heart disease. It is possible that limitation to follow peers and/or parental overprotection have interfered in patients behavior.

The RESULTS suggest THAT ADOLESCENTS WITH HEART DISEASE may have inner resources in order to face adversity in an adaptative fashion.

PEDIATRIC CARDIOLOGY UNIT

SÃO PAULO HOSPITAL - BRAZIL

Authors

Da Silva, Maria Marta – Psychologist Carvalho, Antonio Carlos - CardiologistDiógenes, Maria Suely Bezerra - Cardiologist

mamaferrero@gmail.com

THANK YOU!

mamaferrero@gmail.com