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Abstract A study was made of 26 adolescents, aged from 13 to 18 years, with different types of severe congenital
heart disease, assessing their somatic condition and its impact on mental health and psychosocial functioning.
Physical capacity was reduced, more pronounced in girls than in boys, along with an increased rate of psychiatric
problems. Associations were found between physical capacity and psychosocial functioning, and between psychosocial
functioning and chronic family difficulties. On the other hand, half the patients studied achieved fair function, both
physically and with regard to their mental health. The degree of reduced physical capacity is an important etiological
factor for impaired mental health in patients with congenital heart disease. This knowledge should be taken into
account when dealing with this group of patients. A good social network seems to be a protective factor. It will
probably be rewarding to give patients and their families not only an optimal medical follow-up, but also
psychological, practical and financial support to improve or create such a network.
Key words: Congenital heart disease; physical disability; mental health; psychosocial functioning; adolescents
The project was financed by The National Hospital, The Child Psychiatric Clinic
at the University of Oslo and the Norwegian Directorate of Health.
Correspondence to Dr. Per G. Bjornstad, Pediattic Cardiology, Rikshospitalet,
The National Hospital, University of Oslo, Pilestredet 32, N-0027 Oslo,
Norway. Tel. 47-228 690 92; Fax. 47-228 691 01.
Accepted for publication 02 June 1994
Vol. 5, N o . 1
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Bjornstad et al Physical and psychosodal status in adolescents widi congenital heart disease
Table 1. Somatic diagnosis and latest type of operation in adolescents with severe congenital
cardiac malformation (n=26).
Diagnosis
None
Fallot's anomaly with pulmonary atresia or severe
stenosis requiring a valved conduit
Univentricular atrioventricular connection with or
without tricuspid atresia
Pulmonary atresia or severe stenosis with DORV
or complex transpositions
Ebstein's malformation
Severe left-sided valvar disease with valvar replacement
Aortic
Mitral
Total
Type of operations
Repair
Palliation
Total
10
_
-
4
1
_
-
4
1
18
26
16
17
18
;dBoys GirlsJ
Mean
SD
Range
Age (years)
Percentiles (height)
Percentiles (weight)
Days in our hospital
Admissions here
Catheterizations
Operations
16.3
31
47
80.0
7.5
1.7
24
36
46.5
2.7
13- 18
10<3 - 75
10<3-2>97
6 - 178
3 - 12
4.7
1.8
2-9
2.3
1.3
0-5
58
January 1995
assessment, global assessment and chronic family difficulties were checked and found satisfactory as reported
elsewhere by Bjornstad, Lindberg & Spurkland.15 Socioeconomic status was classified according to national
criteria.
Statistical procedures
In most instances non-parametric tests were used, because our data only rarely were normally distributed and
continuous. For correlations the Spearman rank correlation coefficient was used, with contingency tables and
Chi square test used to test binomial variables. Differences in paired observations were assessed with Wilcoxon's rank sum test. Group analysis was performed either
with the Kruskall-Wallis test, or Mann-Whitney's l i test. The parameters were entered into a data base in an
IBM 4341 computer. The calculations were made with
BMDP Statistical Software, version 1983 (UCLA, Los
Angeles, CA, USA). A statistical p-value 0.05 was
considered "significant," a value 0.01 "highly
significant," and lower values "very highly significant."
These terms are subsequently used in place of specific pvalues in the text.
Ethical aspects
In each case, written informed consent was obtained for
the study and additionally given separately for videotaping of the interviews for the assessment schedule.
The study was approved by the ethical committee of
The National Hospital.
Results
Clinical status
Eight patients were visibly cyanotic, while six had
clubbing. One was slightly cyanotic and the rest were
acyanotic. Whereas the mean height and weight were in
the normal range, some patients were very short and
markedly underweight (Table 2).
Seven patients had scoliosis, but none was in need of
treatment. Some sort of thorax deformity was seen in 11
patients, mostly pectus carinatum. Some of these patients complained about the shape of their thorax, but
again there was no indication for treatment. Deficiencies in the pulses lacking in one or two of the limbs were
discovered in six patients after surgery or catheterization. No trophic disturbance was discovered in any of
them, but half of them said, when asked, that they were
often cold in the specific limb.
Fourteen patients are on cardiac medication, mostly
digoxin. All patients with mechanical valves are on
warfarin. Some take diuretics or afterload reducing
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6
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BjornstadetaL Physical and psychosocial status in adolescents with congenital heart disease
2
0
III
Boys
Girls
Total
Overanxious disorder
Separation anxiety
Major depression
Dysthymic disorder
Attention deficit disorder
Conduct disorder
4
1
2
1
-
2
2
1
2
_
1
6
3
1
4
1
1
14
22
Diagnosis in N of patients
12
Psychiatric diagnosis
1
IV
Boys Girls
Figure 2. Physical capacity according to the classification of
the New York Heart Association7 of adolescents with serious
congenital heart defect. Number of patients on the vertical,
functional class on the horizontal axis.
100-80
70-60
50-40
Boys Girls I
Figure 3. Psychosocialfiinctioning according to childrens'
global assessment scale10 of 26 adolescents with severe
congenital heart defect. Number of patients on the vertical,
functional score on the horizontal axis.
60
NYHA
CGAS
CFD
CAS
CGAS
CFD
CAS
CBCL
-0.40-
0.06"
-0.66s
0.460.67s
0.24"
0.64s
0.55*
0.60s
0.28"
Heart Association and the scores on the child assessment schedule, the children's global assessment scale,
chronic family difficulties and child behavior checklist
are listed in Table 4.
Discussion
The most important findings in this study are the high
frequency of major psychiatric problems noted in this
group of adolescents with severe congenital heart disease, and the significant correlation found between the
psychosocial function and physical capacity (Table 4).
The psychiatric problems are atypically for age as far
as boys are concerned, mostly representing anxiety and
depressive disorders. These seem very likely to be caused
by the impact of the life threatening and incapacitating
cardiac malformation itself.
Psychosocial functioning was found to be poor in
nine patients (35%), and reduced in another nine. This
is definitely more than is expected in the general population,17 and demonstrates the need for attention to be
paid also to the mental health in general of this group of
patients. Moreover, the degree of psychosocial and
physical function correlate significantly. This demonstrates that the more reduced the physical capacity of
the patient, the higher the risk for developing psychiatric disorders. This is in keeping with the findings of
Steinhausen et al,18 Wallander et al19 and Engstrem.20
Several previous studies in patients with congenital
heart defects,1"4 nevertheless, found little or no increase
in emotional problems, and no consistent relationship
between organic severity and psychosocial function.
North et al21 may have shown a possible explanation
for such discrepancies. Studying 138 reports on psychiatric factors in ulcerous colitis, they found that 131 of
them contained serious deficiencies in research methodology.
The mothers make accurate judgments of the physi-
January 1995
Vol. 5, N o . 1
Bjornstadetah Physical and psychosocial status in adolescents with congenital heart disease
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January 1995
23. Puig-Antic J, Chambers WJ, Tabrizi MA. The clinical assessment of current depressive episodes in children and adolescents: Interviews with parents and children. In: Cantwell DP,
Carlson GA (eds). Affective Disorders in Childhood and
Adolescence: An Update. Spectrum Publications, New York,
1983.
24. Rutter M. Resilience in the face of adversity: protective factors
and resistance to psychiatric disorder. Brit J Psych 1985; 147:
598-564.