Anxiety and ADHD in Patients With Single-Ventricle Congenital Heart Disease
Mental health clinicians should remain alert for ADHD and anxiety disorders in adolescents with single-ventricle congenital heart disease.
In a cross-sectional study recently published in Pediatrics, researchers at Boston Children's Hospital and Harvard Medical School in Massachusetts found that adolescents with single-ventricle congenital heart disease (CHD) have a fivefold increase in rates of anxiety disorders and attention-deficit/hyperactivity disorder (ADHD) compared with healthy control patients.1
Approximately 1% of newborns in the United States have CHD, of which one-third have critical CHD requiring catheter-based intervention or cardiac surgery. The highest-risk group are infants with single-ventricle CHD, who "typically require 3 reconstructive open-heart surgeries in the first years of life, with the third stage being the Fontan procedure," wrote the authors of the new study.
As mortality and morbidity have decreased for children with critical CHD, it has become apparent that they suffer from higher-than-average rates of psychiatric and neurodevelopmental disorders such as executive function deficits and ADHD.2,3 Although previous findings show an increased risk for mental disorders such as depression and anxiety in heterogeneous CHD populations, this link has not been adequately examined in patients with critical CHD.4,5
Noting that individuals with single-ventricle CHD may have genetic abnormalities that negatively affect psychiatric and neurodevelopmental functioning, the present study compared psychiatric, neurodevelopmental, and brain MRI outcomes of 156 adolescents with single-ventricle CHD with those of 111 healthy controls. The CHD group consisted of patients aged 10-19 years who had undergone the Fontan procedure. They expected to find an elevated prevalence of ADHD and anxiety in the CHD group, and less psychiatric morbidity in patients without vs with genetic abnormalities.
The results show the following observations in the CHD group vs control patients:
- Higher rates of lifetime psychiatric diagnosis (65% CHD vs 22% controls; P <.001)
- A fivefold increase in the rate of lifetime anxiety disorder diagnoses (35% CHD vs 7% controls, P <.001)
- A similar increase in the rate of lifetime ADHD diagnosis (34% CHD vs 6% controls, P <.001)
- Lower psychosocial functioning, as measured by the Children's Global Assessment Scale (CHD median [interquartile range]: 62 [54–66], controls: 85 [73–90]; P <.001)
In addition, the findings reveal that risk factors for these outcomes include male sex, lower birth weight, lower intellectual functioning, and longer duration of deep hypothermic circulatory arrest. Although there was a significant association between genetic abnormalities and lower Children's Global Assessment Scale scores, no such association was found for the increased risk for anxiety or ADHD diagnoses.
The neuropsychological deficits in visual-perceptive skills and executive function may be related to central nervous system white matter injury that occurred before birth in youth with critical CHD, explained lead study author David R. DeMaso, MD, psychiatrist-in-chief and chairman at Boston Children's Hospital, and professor of child psychiatry and pediatrics at Harvard Medical School, Boston, Massachusetts. "The development of disabling anxiety may be a result of interactions between possible direct effects of brain anxiety circuitry or the indirect effects of patients and families managing their neuropsychological deficits; for example, anxiety related to visual-perceptive skills that impede academic functioning," he told Psychiatry Advisor.
Mental health clinicians should remain alert for ADHD and anxiety disorders in this patient group, as well as academic challenges arising from their neuropsychological vulnerabilities, Dr DeMaso advises. Future research in this area should attempt to further elucidate outcomes in these patients and to assess the effect of early intervention. "Youngsters with critical CHD are living into adulthood — we need to better understand this transition," he said.
- DeMaso DR, Calderon J, Taylor GA, et al. Psychiatric disorders in adolescents with single ventricle congenital heart disease [published online February 1, 2017]. Pediatrics. doi: 10.1542/peds.2016-2241
- Bellinger DC, Watson CG, Rivkin MJ, et al. Neuropsychological status and structural brain imaging in adolescents with single ventricle who underwent the Fontan procedure. J Am Heart Assoc. 2015;4(12):e002302. doi: 10.1161/JAHA.115.002302
- Bellinger DC, Wypij D, Rivkin MJ, et al. Adolescents with d-transposition of the great arteries corrected with the arterial switch procedure: neuropsychological assessment and structural brain imaging. Circulation. 2011;124(12):1361-1369. doi: 10.1161/CIRCULATIONAHA.111.026963
- Luyckx K, Rassart J, Goossens E, Apers S, Oris L, Moons P. Development and persistence of depressive symptoms in adolescents with CHD. Cardiol Young. 2016;26(6):1115-1122. doi: 10.1017/S1047951115001882
- Kovacs AH, Saidi AS, Kuhl EA, et al. Depression and anxiety in adult congenital heart disease: predictors and prevalence. Int J Cardiol. 2009;137(2):158-164. doi: 10.1016/j.ijcard.2008.06.042