1. 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 - Brazil Division of Cardiology Pediatric Cardiology Unit of São Paulo Hospital

2. 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

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

4. 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.

5. 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

6. 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

7. 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.

8. 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

9. 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. OBJECTIV E

10. MATERIAL AND METHODS Study Group 376 participants Age: 11-18 years 130 adolescents with heart diseases 56,9%: male 43,1%: female 246 healthy adolescents 48,0%: male 52,0%: female Primary Caregivers Control Group 130 parents

11. INSTRUM ENTS  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 screening Intensity: score ranges (0, 1, 2)

12. ANALYSIS OF RESULTS Total Problems Internalizing scale Externalizing scale Subscales Reported behaviors I – Withdrawn II – Somatic Complaints III – Anxiety/Depression IV – Social Problems V – Thought Problems VI – Attention Problems VII – Delinquent Behavior VIII – Agressive Behavior

13. PROCED URE 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.

14. 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

15. RESU LTS

16. Distribution of male adolescents with or without heart disease according to the YSR scales and subscales YSR subscalesYSR scales * * * * % *

17. Distribution of female adolescents with or without heart disease according to the YSR scales and subscales YSR subscalesYSR scales * % *

18. Distribution of adolescents with or without heart disease according to gender for the YSR scales and subscales YSR scales YSR subscales * * %

19. Comparison between operated and non-operated male adolescents with heart disease according to the YSR scales and subscales YSR scales YSR subscales %

20. Comparison between operated and non-operated female adolescents with heart disease according to the YSR scales and subscales YSR scales YSR subscales %

21. Comparison between adolescents with congenital and acquired heart disease according to the YSR scales and subscales YSR scales YSR subscales %

22. Comparison between adolescents with acyanotic or cyanotic heart disease according to the YSR scales and subscales YSR scales YSR subscales %

23. Distribution of delayed or non-delayed schooling adolescents with heart disease according to the YSR scales and subscales YSR scalesYSR subscales * * % * *

24. Distribution of male adolescents with heart disease according to age groups classified for the YSR scales and subscales YSR scalesYSR subscales * * %

25. Distribution of female adolescents with heart disease according to age groups classified for the YSR scales and subscales YSR scales YSR subscales * * * * ** %

26. Distribution of adolescents with heart disease compared with parents classified for the YSR and CBCL scales and subscales YSR scalesYSR subscales * * * * * %

27.  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. CONCLUSI ONS

28.  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. CONCLUSI ONS

29.  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. CONCLUSI ONS

30. FINAL CONSIDERATION S  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.

31. PEDIATRIC CARDIOLOGY UNIT

32. SÃO PAULO HOSPITAL - BRAZIL

33. Authors Da Silva, Maria Marta – Psychologist Carvalho, Antonio Carlos - Cardiologist Diógenes, Maria Suely Bezerra - Cardiologist mamaferrero@gmail.com

34. THANK YOU! mamaferrero@gmail.com