Psychosomatics 41:134-139, April 2000
© 2000 The Academy of Psychosomatic Medicine
Psychological Functioning in Children and Adolescents Undergoing Radiofrequency Catheter Ablation
David Ray DeMaso, M.D., ,
Eve Garlington Spratt, M.D.,
Brigid L. Vaughan, M.D., ,
Eugene J. D'Angelo, Ph.D.,
Julie R. Van der Feen, M.D., , and
Edward Walsh, M.D.
Received March 3, 1999; revised June 21, 1999; accepted July 6, 1999. From the Departments of Psychiatry & Cardiology, Children's Hospital/Harvard Medical School, Boston, Massachusetts; the Departments of Psychiatry and Pediatrics, Medical University of South Carolina, Charleston, SC; and the Department of Cardiology, Children's Hospital/Harvard Medical School, Boston, Massachusetts. Address reprint requests to Dr. DeMaso, Department of Psychiatry, Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115.
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ABSTRACT
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This study examined 38 patients (age 6–18 years) with recurrent cardiac arrhythmias who underwent radiofrequency catheter ablation of ectopic myocardial foci. Psychological functioning was assessed by the Pediatric Symptom Checklist, Short Mood and Feeling Questionnaire, Revised Children's Manifest Anxiety Scale, and Arrhythmia Anxiety Queries prior to ablation and at 3-month follow-up. The patients resembled a normal population without elevations in anxiety or depression. After ablation, the patients showed reductions in the "fear of their heart problem" and increases in "the things that they enjoy." The patients who underwent a curative ablation had better functioning than those who did not show improvement. Children appear to have the opportunity for an improved quality of life after ablation.
Key Words: Children • Radiofrequency Catheter Ablation
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INTRODUCTION
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Advances in the diagnosis and management of recurrent cardiac arrhythmia (RCA) have significantly decreased the morbidity rates of affected children.1 The technique of radiofrequency catheter ablation of ectopic myocardial foci and pathways during cardiac catheterization has resulted in cure rates approaching over 90% of patients.2,3 Nevertheless, many youngsters with these disabling arrhythmias have experienced necessary drug treatment trials, outpatient visits, invasive procedures, and hospitalizations before an ablation. The psychological sequelae of living with these chronic, but potentially curable, disorders remain unclear.
The literature dealing with the emotional status of patients with RCA has been limited to adult patients. The major cause of cardiac mortality in the United States is sudden cardiac death, most often the result of a fatal ventricular arrhythmia.4 In adults, underlying ischemic heart disease accounts for most cases of RCA.5 Fricchione and Vlay5 reported that anxiety and depression are two common problems faced by patients who have been diagnosed with dysrhythmias. Fricchione et al.6 further postulated the existence of secondary panic anxiety and withdrawal reactions in patients treated with an automatic internal cardioverter defibrillator.
Dunnington et al.7 found significantly elevated overall psychological distress, including anxiety and depression, in 89 patients with RCA. They found that patients who received long-term antiarrhythmic medications were in greater distress, were forced to modify their work status, and experienced more advanced cardiac impairment. Haggerty et al.8 reported debilitating anxiety and depression in 58% of 33 patients with ventricular tachycardia or fibrillation.
However, these findings in adult populations cannot be generalized to children. Although studies in children and adolescents have focused on the adaptation to congenital heart disease,9–11 there have been no investigations into the emotional responses of children with RCA. Despite the findings in adult studies and frequent clinical assumptions about children's psychological functioning, there has been no specific examination of anxiety and depression in children or adolescents with RCA.
The literature is limited regarding the effects of radiofrequency catheter ablations on the emotional status of patients. Fitzpatrick et al.12 found in a study of 107 adults that their quality-of-life index and daily living activities significantly improved. Bathina et al.13 reported that the quality of life of adult patients treated with ablation improved to a greater extent than those treated with medication. In 161 adults, Bubien et al.14 described a significant improvement in health-related quality of life after catheter ablation that was sustained for 6 months. However, there have been no studies in children or adolescents examining the relationship between ablations and their psychological functioning.
This investigation examines the psychological functioning of children and adolescents with RCA. The study was conducted to analyze the general adjustment, along with the levels of anxiety and depression, in patients with RCA before and after radiofrequency catheter ablation of ectopic myocardial foci. This study is unique in that it is based on pre- and postablation assessments of emotional functioning with a consecutive series of children and adolescents with RCA.
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METHODS
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Sample Selection
The study was conducted over a 1-year period through the Cardiac Arrhythmia Service at Children's Hospital, Boston, Massachusetts. The subjects were children and adolescents with RCA between the ages of 6 and 18 years who were hospitalized consecutively for radiofrequency catheter ablation. Children whose primary educational placement was in a special needs classroom were excluded from the study to ensure proper comprehension of the questionnaires.
The children and their mothers were contacted at two points in the study. They were contacted while hospitalized the day before receiving the ablation procedure. At that time, the mother was administered a standardized general adjustment measure, while a member of the research team read standardized depression and anxiety measures to the child.
The family was then recontacted for telephone interviews 3 months after the procedure. At this time the member of the research team who saw them during the hospitalization again administered the same general adjustment measure to the mother and completed the same depression and anxiety measures with the child. Paulsen et al.15 have demonstrated the reliability of using telephone interviews in eliciting similar data. In the present study, the families received $5 for their participation. Informed consent was obtained from all families.
Sample Characteristics
The subjects were 23 males and 15 females with a mean (±SD) age of 13.1±3.6 years. Families were approached consecutively, with only one declining to participate in the study. All subjects completed both assessment points in the study. The ethnic distribution of the sample was 36 (94.6%) white, 1 (2.7%) Latino, and 1 (2.7%) other. Twenty-seven (71.1%) of the parents were married, with 9 (23.6%) divorced/separated, and 2 (5.3%) single. Socioeconomic level was calculated using the Hollingshead four-factor index.16 The distribution of families on the SES index was 15 (39.5%) major business/professional, 10 (26.3%) medium business/technical, 8 (21.1%) skilled craft/clerical, and 5 (13.1%) semiskilled categories.
The types of RCA treated included intermittent supraventricular tachycardia (42%), Wolff-Parkinson-White syndrome (39.5%), ventricular arrhythmias (5.3%), and other (13.2%). The mean length of time since diagnosis of RCA was 4.6±5.3 years. There were 35 (92.1%) patients with no detectable structural heart disease and 3 (7.9%) with congenital heart disease. Syncope was reported in 26.3% of the children and chest pain in 50%. The mean number of outpatient medical visits was 16.8±25.5. The mean number of cardiac-related hospitalizations was 1.6±3.6. The mean number of antiarrhythmic medications used over the course of the problem was 1.5±1.4 (range: 0–7).
General Adjustment Measure
Pediatric Symptom Checklist (PSC)
The PSC is a 35-item psychosocial screening questionnaire that reflects a parent's perspective of his or her child's psychosocial functioning.17–21 It has been validated for use in children and adolescents age 4–16 in a variety of settings, including primary care and specialty pediatric settings.17–21 It has shown screening accuracy comparable to the Child Behavior Checklist (CBCL), the most thoroughly validated psychiatric screening instrument for children.22 PSC scores of 28 or above indicate those children with substantial psychosocial dysfunction. This form was given to the mother prior to the ablation procedure and 3 months postprocedure.
Depression Measure
Short Mood and Feelings Questionnaire (SMFQ)
The SMFQ is a 13-item self-report measure of childhood and adolescent depression.23,24 The questionnaire given to the child covers the age range of 7 to 18 years.23,24 Results have revealed substantial correlations between the SMFQ, the Children's Depression Inventory,25,26 and the Diagnostic Interview Schedule for Children depression scale.27,28 SMFQ scores of 8 or above indicate a probable diagnosis of depression.23 A member of the research team read the SMFQ to each patient, and their responses were recorded before treatment and 3 months later.
Anxiety Measures
Revised Children's Manifest Anxiety Scale (RCMAS)
The RCMAS is an anxiety outcome measure in children and adolescents.29 It has an excellent normative base with very good psychometric properties for the ages 6–19 years.29 Standard scores have been determined for the total anxiety scale as well as four subscales: social desirability, physiological anxiety, social concerns/concentration, and worry/oversensitivity. Given the presence of cardiac difficulties for these children, the physiological anxiety subscale was especially attractive to use in this pediatric population.
Arrhythmia Anxiety Queries (AAQ)
The AAQ were developed with the cardiologist for this group of children. The cardiologist has found these illness-related anxiety questions clinically important in understanding his patients. The following three questions were asked of the patient: 1) Does your heart problem scare you? 2) Does your heart problem keep you from doing things you enjoy? and 3) Are you afraid to be alone because of your heart problem? Scores were obtained by asking each patient to rate each question on a 3-point Likert scale ranging from never (1), to sometimes (2), to often (3).
The RCMAS and AAQ measures were given to the children and adolescents before the ablation and 3 months after. A member of the research team read both measures to each child, and their responses were recorded.
Measure of Radiofrequency Catheter Ablation Success
The cardiologist reviewed the charts of all patients 9 months after the completion of the study with regard to the success of the ablation procedure. The procedure was scored as either 1) Curative, if there had been no recurrence of the arrhythmia and no antiarrhythmic medication had been required, 2) Improved, if there had been a reduction in frequency of arrhythmia and/or antiarrhythmic medication had been continued after the ablation procedure, or 3) No Change/Worse, if the procedure had resulted in no improvement or worsening in the patient's cardiac status.
Statistical Analyses
The PSC, SMFQ, and RCMAS scores were compared to each scale's mean for "healthy or normal" children using dependent t-tests. The scores from the same measures along with the AAQ scores were then compared before and after radiofrequency catheter ablation using dependent -tests. Mann-Whitney U-tests were used to compare the scores on the measures for the subjects based on the success of the ablation.
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RESULTS
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Descriptive Data
The means and standard deviation scores for the PSC, SMFQ, RCMAS, and AAQ are reported in Table 1. Both pre- and postablation PSC, SMFQ, and RCMAS scores were not significantly elevated compared to the normative population for each measure, suggesting that these patients were not exhibiting emotional or behavioral symptoms at clinically significant levels and were not significantly different from peers without cardiac illness.
Pre- vs. Postablation Comparisons
There was no significant difference in the postablation PSC scores compared to the preablation PSC scores, suggesting that there was little appreciable difference in psychosocial functioning before and after the ablation in these patients. Similarly, no differences were found between the pre- and postablation SMFQ scores for these patients.
The RCMAS's total anxiety scale was not significantly different when preablation scores were compared to postablation scores. Likewise, the physiological anxiety, social concerns/concentration, and social desirability subscales were not significantly different when preablation scores were compared to postablation scores. However, the postablation worry/oversensitivity subscale scores were significantly lower than the preablation scores (t=2.130, P<0.05).
On the AAQ, two of the three items revealed significant differences. There were significantly lower ratings on the "scared of their heart problem" item (t=2.941, P<0.01) and "do the things that they enjoy" item (t=4.158, P<0.001) after the ablation procedure. Interestingly, there were no significant differences noted for the patients' ratings on the "afraid to be alone" item.
Ablation Outcome Comparisons
The review of the success of the ablation procedure showed that 30 (78.9%) of the patients had a curative procedure, 6 (15.8%) had improved, and 2 (5.3%) showed no improvement. Preablation PSC scores showed no significant differences between patients who had a curative procedure compared to those that had either improved or not improved. However, postablation PSC scores were significantly lower in patients who had curative outcomes compared to those of patients who experience some or no improvement from the ablations (=3.50, P<0.05). Comparisons with the depression and anxiety measures showed no significant differences between groups with regard to the success of the ablation.
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DISCUSSION
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The children and adolescents in our sample resembled a normal population in terms of their general adjustment, with comparable levels of anxiety and depression. This stands in contrast to the literature regarding adults with RCA.4–7 Similarly, this finding is consistent with studies of children with congenital heart disease and other medical conditions where overall adjustment was not significantly different from healthy children.10,11,30 Thus, children with RCA revealed the resiliency and adaptive potential demonstrated in other pediatric chronic illness populations.30–32
Although there were no significant differences between pre- and postablation general adjustment and depression scores, some significant differences were found on the anxiety measures. In particular, the postablation worry/oversensitivity subscale scores on the RCMAS were significantly lower than the preablation scores. The elevated scores in this category are indicative of a child who is afraid, nervous, or in some manner oversensitive to environmental pressures.29 A higher score on this scale suggests that a child who internalizes much experienced anxiety may become overburdened trying to relieve this anxiety. These children may have difficulties learning to share these feelings in a more open manner.29 One possible interpretation of the lower scores postablation is that the children in this study faced stress dealing with their RCA due to repetitive worrying about their condition. After the transcatheter ablation procedure, these children may have experienced relief over having fewer cardiac symptoms and needing less medical follow-up.
The RCMAS's physiological anxiety and social concerns/concentration subscale scores were not significantly different between pre- and postablation measures. The former subscale is an index of the child's expression of physical manifestations of anxiety, whereas the latter is a measure of concern about self vis-à-vis other people, along with difficulty concentrating.29 The lack of significant findings on these scales may be further reflection of the psychological resilience of these children and adolescents. Although the social desirability subscale scores did not appear indicative of inaccurate self-report, the lack of expression of physiological anxiety in these children with RCA needs further study.
Two of the three AAQ were significantly different pre- vs. postablation. The patients showed significant reductions in the fear of their heart problem along with a corresponding increase in "the things that they enjoy" after the ablation. There was no change in their being "afraid to be alone," which had been low before ablation. These questions look directly at the impact of the illness on the patient's anxiety. These findings are of particular interest because the three questions do not focus on "situational anxiety" (e.g., anxiety associated with being admitted to a hospital), but are directed at how concerns about one's cardiac condition affected the child's social functioning. Given that the initial assessment occurred at the time of hospital admission, the postablation reduction in anxiety could either represent the relief at completing a procedure that involved an acute hospitalization or be directly attributed to the outcome of the procedure.
Almost 80% of the patients in this study had a curative procedure for their RCA after the transcatheter ablation. These patients no longer require antiarrhythmic drug therapy or repeated hospitalizations and invasive procedures.1–3 Compared to those who did not have a curative procedure, these patients had significantly lower postablation PSC scores indicative of better psychosocial functioning. This change, together with the changes in the anxiety measures, does suggest that after curative ablation these patients now have the emotional opportunity for their quality of life to improve. Physicians might be especially alert for possible adverse psychological responses in patients who do not have a successful ablation outcome.
The sampling of consecutive child and adolescent patients with RCA undergoing radiofrequency catheter ablation is a unique feature of this analysis. The results are based on parent and child reports of psychological functioning rather than a single reporter as in many studies of psychological functioning. The findings are further strengthened by the comparison between pre- and postablation assessments.
The following limitations warrant further investigation and an expanded effort to replicate these findings. First, the sample size is relatively small. An increase in sample size would allow for multivariate analyses to assess the relative importance of demographic or medical severity variables in predicting child adjustment. Second, the effects of developmental differences in coping were also difficult to control in this study, given the wide age range in the sample. Third, given the small number of minority and lower SES families, the generalization of these findings to more heterogeneous populations is also questionable. Fourth, the close proximity of our assessment to the ablation procedure makes it difficult to separate the impact of the hospitalization from that of the ablation outcome. For example, the lack of difference on the measures from normative populations may reflect an element of "stoic" denial at work that is related to the impending surgery rather than the impact of the arrhythmia overall. Finally, this study did not examine other possible risk factors, such as temperament or parent–child interactions, which might also influence psychological functioning.
This study underscores that children and adolescents with RCA have the capacity for healthy psychological functioning. It describes a reduction in fear and an increased ability to enjoy life after a successful transcatheter ablation of cardiac arrhythmias. From a clinical perspective, this work supports the positive emotional impact that this procedure can have for these patients and their families. In the circumstance of a less successful treatment outcome, the physician should be alert for general adjustment problems and the possible need for psychological intervention. Overall, children and adolescents after radiofrequency transcatheter ablation appear to have the opportunity for improved psychological functioning.
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ACKNOWLEDGMENTS
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The authors thank Felton Earls, M.D., and Anne Niec, M.D., for their support of this project.
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REFERENCES
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- Gillette PC, Garson A, Crawford F, et al: Dysrhythmias, in Pediatric Cardiology. Edited by Anderson RH, Shinebourne EA, Macartney EJ, et al. New York, Churchill Livingstone, 1987, pp 925–939
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M. Cohen, D. Mansoor, H. Langut, and A. Lorber
Quality of Life, Depressed Mood, and Self-Esteem in Adolescents With Heart Disease
Psychosom Med,
May 1, 2007;
69(4):
313 - 318.
[Abstract]
[Full Text]
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ABSTRACT
INTRODUCTION
