A Controlled Study On Psychological Characteristics Of Children With Congenital Heart Diseases And Effects On Mentality And Behavior After Different Treatment Methods

Congenital heart disease(CHD) occurs in at least 6-8 per 1000 live-born children, making it the most common category of congenital structural malformation. CHD is the second most prevalent chronic disease in childhood. Improvements in traditional cardiac surgery and the more and more popular interventional therapy have dramatically reduced the mortality in children with CHD, leading to better survival of individuals. Recent estimates have indicated that approximately 85%-90% of children with CHD are expected to reach adolescent or even adulthood. Living with heart disease can have deleterious effects on psychological consequences for children, but researches to date have contradictory results. Some studies reported higher levels of mental and behavioral problems than those of healthy children. Other children reported lower levels of mental and behavioral problems, or no difference from control groups. Furthermore, these contrasting results all come from children after cardiac surgery, but for psychological behaviors after the interventional therapy, to date, there haven't been relative studies reported.1. ObjectiveThe aim of the present study is to assess the psychological characteristics of children with congenital heart disease (CHD) and to compare post operative mentality and behavior between children who received interventional therapy and congenital heart surgery. Results from this study will provide practitioners with updated information that can be used to assess the psychological characteristics of CHD children in the whole course of disease and to conduct interventions to facilitate children getting real health early.2. Methods2.1 Patients191 children suffering from congenital heart diseases collected from hospitals affiliated to Shandong university, who were treated from July 2004 to July 2007, were included in the study to assess the psychological characteristics. They are aged from 6 to 11 years old,78 among them were in cyanotic group, which has 45 boys, mean age (6.87±1.55) years old; and 33 girls, mean age (7.02±1.46) years old. The acyanotic group contains 113 subjects,58 are boys, mean age (9.12±1.35). The rest of 55 are girls, mean age (8.66±1.13).In order to compare 6-month-post-operative mentality and behavior in children receiving interventional therapy and congenital heart surgery,127 children with Atrial Septal Defect (ASD) or Ventricular Septal Defect (VSD) were divided into two groups:interventional and surgical groups. The surgical groups were comprised of 61 children (33 males,28 females), while the interventional group comprised of 66 children (35 males,31 females). Patients with chromosomal aberrations or extracardiac malformations were absolutely excluded. The inclusion criteria for the study group were defined by the diagnosis of an acyanotic heart condition with only one malformation. And the rank of age was confined to 6-11 years old. All the children's cardiac function was normal, assigned according to the classification system the Cardiology Committee of the Pediatrician Society of P.R.China. Sixty healthy children (30 males,30 females) were enrolled as controls.Meanwhile, one hundreds and sixty children suffering from VSD or ASD, without associated other structural cardiac anormalies were evaluated to compare the influence on mentality and behavior 12-month-after surgical procedure versus interventional therapy, including surgical group(n=80) and interventional group(n=80).In each group there are 40 boys and girls,and also we divided into two subgrouops,older group(n=20) and younger group(n=20). The inclusion criteria of the patients and controls are the same as the former.All the control groups did not differ significantly in their mean ages, sex distributions or the parents'socioeconomic status. Children for the reference group should not have any history of chronic disorders and/or major illness requiring previous hospitalizations or surgeries. The controls had normal cardiovascular structural formation examined by echocardiography.2.2 Measure instruments2.2.1 Personality testWe used an adapted version of the Eysenck Personality Questionnaire (the edition for children, EPQ) as an assessment instrument for personality, which consists of 88 items that are under four subcategory scales, including neuroticism, extraversion/introversion, psychoticism and lie. The doctors ask subjects questions and then to fill in the form.2.2.2 Behavior testAchenbach Child Behavior Checklist (CBCL) is completed by parents. First explain the scale and how to fill it to the parents in detail. And then, they answer the items one by one according to what children performed in the last six months. It consists of 113 items related to behavior problems which are scored on a 3-point scale ranging from not true to often true of the child. Scoring will yield a total score, as well as syndrome scores such as anxiety, attention problems, and depression. Every behavior problem has one raw score, all items' raw point in one factor amounts to the factor's score. The sum of all items is the total raw score. The points higher, the behavior problem more serious.We also performed Achenbach Child Behavior Checklist(CBCL) on the children 6 months and 1 year after the treatment.2.2.3 Intelligence TestUsing the Chinese Combined Raven's Test (CRT) manual to test. There are 72 items altogether and they are divided into 6 parts:A, AB, B, C, D and E. Among them, A, B and AB are used to test the ability to distinguish and observe directly, while C, D and E focus on analogical reasoning ability. The children were tested one by one on the basis of the manual. They will be asked to finish the test in 40 minutes.2.2.4 Adaptive behavior testSocial adaptive behavior (SAB) manual is carried out. It contains 8 subscales. The parents were inquired item by item, then the form will be filled. Each subscale gets a raw score, they can be summarized into independent functional factor, cognitive factor and social/self-control factor.2.3 Statistical AnalysisThe results are expressed as mean (SD) or in the form of percentages. The t-test was applied for the comparison of mean values, and the chi-square test was administered for comparison of frequencies. For intergroup comparison of clinical variables, the nonparametic q test was utilized. Statistical analysis was performed with SPSS for windows software version 13.0. P values <0.05 were considered significant.3. Results3.1 Psychological characteristics of CHD children3.1.1 Comparison of EPQ test resultsThe point of the CHD group is significantly higher than the control group (P<0.001), the cyanotic children showed obviously higher scores compared to acyanotic children (P<0.05).3.1.2 Comparison of CBCL test resultsThe detection rate of behavior abnormities of the CHD group were obviously higher than the control group (P<0.01 or P<0.001). The cyanotic children showed higher scores compared to acyanotic children, and there is Statistical significance(P<0.05).The boys with CHD mainly perform abnormal behavior such as depression, social withdrawal, physical complaints, assault and violate rules. Among them, children in cyanotic group significantly present assault behavior. Whereas the girls presented as depression, social flinch, physical complaints and violate rules, in which cyanotic group performs significantly on depression and social flinch.3.1.3 Comparison of CRT test resultsThere was no significant difference between the acyanotic group (107±13) and the controls (109±11) in the mean IQ (P>0.05), however, the IQ score of cyanotic group(96±12) was lower than that of controls(P<0.05). Among all the parts in the test, the cyanotic group receives lower points in D part and E part.3.1.4 Comparison of SAB test resultsThe adaptive deviation quotient (ADQ) of the CHD groups was significantly lower than that of he healthy control group (P<0.05). The independent functional factor and social\self-control factor are obviously lower than the control group (P <0.01 or P<0.05). the adaptive deviation quotient (ADQ) and the independent functional factor of the cyaotic group are significantly lower than the control group (P<0.01) and lower than the acyaotic group (P<0.05).Points on cognitive factor and social\self-control are lower than the control (P<0.01, P<0.05)3.2 Mentality and behavior of CHD children after different treatments3.2.1 Assessment after 6 months of the treatmentsI Mentality and behavior abnormal rates assessmentParent's reports revealed significantly higher mental and behavioral abnormality rates of CHD children groups compared to the control subjects. The pre- and post-operative abnormal rates of surgical boys were 39.4%(3/33),27.3%(9/33) respectively, and were 40.0%(14/35),20.0%(7/35)of the interventional boys respectively, both of which were significantly higher than that of the control groups, 6.7%(2/30)(X2=15.56,13.31,18.82,31.73, P<0.01). The pre- and post-operative abnormal rates of surgical girls were 42.3%(12/28),28.6%(8/28)respectively, and were 38.7%(12/31),22.5%(7/31)of the interventional boys respectively, both of which were also significantly higher than that of the control groups,3.3%(1/30) (X2=20.38,21.47,16.75,15.26, P<0.01). ⅡMental and behavioral assessment:CHD groups versus controls.In CBCL, the total scores of CHD groups were significantly higher than those of the control groups (P<0.01). The abnormal behaviors of the boys were presented as depression, social difficulties, somatic complaints, social flinch, delinquency (P<0.01), and aggression (P<0.05), whereas in the girls were presented as depression, social flinch, somatic complaints, and delinquency (P<0.01).ⅢMental and behavioral assessment:Before and after the treatments.The total cursory mark of post-operative check result of the interventional and surgical children, both in girls and in boys, were significantly lower than those of the preoperative children(P<0.01)ⅣMental and behavioral assessment:Interventional groups versus surgical groups.The aggression and total cursory mark of post-operative check result of boys treated with interventional therapy were significantly lower than those of boys treated with surgical operations (P<0.05). The depression, social flinch, delinquency and total cursory mark of post-operative check result of girls treated by interventional therapy were significantly lower than those of girls treated by surgical operations (P<0.05).3.2.2 Assessment after 12 months of the treatmentsⅠMentality and behavior abnormal rates assessmentParent's reports showed significantly higher mental and behavioral abnormality rates of CHD children groups compared with in the control subjects. The preoperative abnormal rates of surgical children were 30.0%(12/40),32.5%(13/40) respectively, and were 32.5%(13/40),37.5%(15/40)of the interventional children respectively, both of which were significantly higher than that of the control groups 6.7%(2/30), 10%(3/30) (X2=17.12,13.34,19.57,20.59, P<0.01). The post-operative abnormal rates of surgical chilrend were 20%(8/20),22.5%(9/20)respectively, both of which were also higher than that of the control groups (X2=7.47,8.36, P<0.05).While, The post-operative abnormal rates of interventioanal chilrend showed no difference than that of the control groups. ⅡMental and behavioral assessment:CHD groups versus controls.In CBCL, the total scores of CHD groups were significantly higher than those of the control groups (P<0.01). The abnormal behaviors of the boys were presented as depression, social difficulties, somatic complaints, social flinch, delinquency (P<0.01), and aggression (P<0.05), whereas in the girls were presented as depression, social flinch, somatic complaints, and delinquency (P<0.01).ⅢMental and behavioral assessment:Before and after the treatments.The total cursory mark of post-operative check result of the interventional and surgical children, both in girls and in boys, were significantly lower than those of the preoperative children(P<0.01)ⅣMental and behavioral assessment:Interventional groups versus surgical groups.The aggression and total cursory mark of post-operative check result of boys treated with surgical operations were significantly higher than those of boys treated with interventional therapy (P<0.05). The depression, social flinch, delinquency and total cursory mark of post-operative check result of girls treated by surgical operations were significantly higher than those of girls treated by interventional therapy (P<0.05).While, The total cursory mark of post-operative check result of children (both girls and girls) treated with interventional therapy showed no difference than that of the control groups(P>0.05).ⅤMental and behavioral assessment between different age groupsThe total cursory mark of older children was significantly higher than those of the younger ones before treatments (P<0.05). The postoperative total cursory mark of older children treated with surgical operations was higher than those of the younger controls in the same treatment group (P<0.05). The postoperative total cursory mark of older children treated with interventional therapy showed no difference than those of the younger controls in the same treatment group (P>0.05).4. ConclusionsCHD is associated with personality characteristics of neuroticism and abnormal behavior of the children. The social adaptive behavior of the CHD children, and the intelligence quotients in cyanotic children were significantly lower with comparison to the healthy children. Early treatments, especially the interventional therapy can significantly alleviate the mental and behavioral abnormality of children with CHD. Children after surgery remain more mental and behavioral problems than those after interventional therapy in a certain period, which should be paid more attention to.