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Behavioral problems in adolescents with cardiac disease: an exploratory study in a
pediatric cardiology outpatient clinic
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
THANK YOU!