Counselling strategies for parents of infants with congenital heart disease

Burnout: Can we help?

The recent editorial highlighting factors that may lead to burnout among the paediatric fraternity drew attention to those at most risk. They included 'intelligent, committed, single young women' more so then men and those who were 'high achievers with empathy who take the patients' problems to heart'. Yet little appears to be available to ameliorate the stresses experienced by clinicians while building their resilience and improving their understanding of the interactions between themselves and the patient/parents. Drawing on past experience, a psychologically orientated approach to clinical care is emphasised. This approach required greater knowledge of one's self together with the need to commune with like-minded colleagues. That led to a Balint-type weekly group led by a child psychiatrist where experiences were exchanged, new knowledge acquired and mutual support provided. That in turn led to further study and the acquisition of new skills, including ongoing supervision to achieve a therapeutic interview. The latter was facilitated by carefully listening to the patient/parent, recognising the hidden agenda, struggling with non-compliant parents and appreciating concepts such as transference and counter-transference as it related to the patient-doctor interaction. Such insights may help paediatricians improve their therapeutic effectiveness and increase their personal satisfaction, thus adding a bonus to the essential requirement of a knowledge-based diagnosis and management plan. Yet, only a few avenues are available to acquire such experiences, which need to be made available not only to those who recognise their importance but to all. How best to achieve these goals remains unresolved.

Association between polymorphisms in AXIN1 gene and atrial septal defect

CONTEXT

AXIN1 is a central component of Wnt signalling pathway which is essential for embryonic development.

OBJECTIVE

To investigate whether polymorphisms of AXIN1 contribute to ASD susceptibility.

MATERIALS AND METHODS

Three tag SNPs (rs12921862, rs370681 and rs1805105) in AXIN1 were genotyped in 208 ASD patients and 302 healthy controls using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) in a Chinese population.

RESULTS

Significantly increased ASD risk was observed to be associated with the A allele of rs12921862 (p < 0.0001, OR = 3.096, 95% CI = 2.037-4.717). Increased ASD risk was observed to be associated with rs370681 in a codominant (p = 0.043, OR = 1.52, 95% CI = 1.04-2.22) and overdominant model (p = 0.016, OR = 1.57, 95% CI = 1.08-2.27).

CONCLUSION

rs12921862 and rs370681 may contribute to ASD susceptibility.

Infant cardiac surgery: mothers tell their story: a therapeutic experience

BACKGROUND

Serious congenital heart disease frequently requires major congenital heart surgery. It causes much distress for parents, which may not always be recognized and treated appropriately.

PATIENTS AND METHODS

As part of a larger study, 26 mothers of two-month-old infants subjected to recent cardiac surgery were interviewed in depth. Each mother was invited to describe her own and what she perceived were her infant's experiences and to comment on the interview process. A systematic content analysis of the interviews was performed using qualitative research methodology.

RESULTS

Almost all participants described acute stress symptoms relating to the diagnosis and the infant's surgery. In addition, most mothers reported that the interview helped them to think about and integrate what had happened to them and their infant, suggesting a probable therapeutic value to the interview.

CONCLUSIONS

A suitably qualified and experienced mental health professional, assisting the mother to tell her story about the diagnosis and her infant's cardiac surgery, may provide a valuable, brief, and very cost-effective therapeutic intervention for these mothers and infants. It has the potential to alleviate maternal distress, with associated gains for the developing mother-infant relationship, reducing infant morbidity, and enhancing the quality of life for both infant and mother.

Children's and adolescents' understanding of their small ventricular septal defects

BACKGROUND

Congenital heart disease is common yet poorly understood in childhood. We reviewed the understanding of older children and adolescents with the commonest congenital heart defect, namely, a small ventricular septal defect (VSD), through a questionnaire and/or their drawings of their abnormality.

METHODS

As part of a wider study, older children and adolescents with a small VSD were asked to draw a picture of their cardiac defect in addition to completing a questionnaire.

RESULTS

Twelve of an initial cohort of 20 participants, who were between the ages of 8 and 20 years, completed a drawing of their malformation. Further drawings were obtained from five additional participants recruited from a private practice over the next few years. There were almost equal number of male and female participants overall. Nearly all participants had a limited understanding of their cardiac abnormality as reflected by their drawings. Nevertheless none reported restricting their physical activity.

CONCLUSION

While most older children and adolescents did not seem to have a clear understanding of their small VSD, it did not appear to affect their daily activity. The participants placed a greater reliance on the information provided by their parents rather than their doctor, emphasizing the importance of informing both the parents and the patient.

Breaking bad news: an interview study of paediatric cardiologists

Technical developments in paediatric cardiology over the last few decades have increased expectations on professionals, demanding of them more emotional competence and communicative ability. The aim of this study was to examine the approach of paediatric cardiologists in informing and communicating with the family of the patient.

METHOD

A qualitative interview method was first tested in a pilot study with two paediatric cardiologists. There were nine subsequent semi-structured interviews that were carried out with paediatric cardiologists. A researcher performed all the interviews, which were taped, transcribed, decoded, and analysed.

RESULTS

Among paediatric cardiologists, how to break bad news to the family is an important concern, evident in findings regarding the significance of trust and confidence, the use of different emotional positions, and a common ambition to achieve skills to handle the situation. There is a need for reflection, education, and sharing of experiences. The cardiologists desire further development of teamwork and of skills in medical students and residents for delivering bad news.

CONCLUSIONS

Doctors are expected to cope with the complexities of diagnoses and decisions, while simultaneously being sensitive to the feelings of the parents, aware of their own emotions, and able to keep it all under control in the context of breaking the bad news to the parents and keeping them informed. These conflicting demands create a need to expand the professional role of the doctor by including more training in emotional competence and communicative ability, beginning in medical school and continuing through consultancy.

A multicentric study of disease-related stress, and perceived vulnerability, in parents of children with congenital cardiac disease

Parents of children with congenitally malformed hearts can suffer from stress as a result of the medical condition of their child. In this cross-sectional study, we aimed to describe levels of parental stress, and perceived vulnerability, in parents of children who underwent major cardiac surgery, by using both generic and disease-related measures for assessment. We included parents of children who underwent open-heart surgery over the period 2002 through 2007 in the Center for congenital Anomalies Heart Amsterdam/Leiden, abbreviated to provide the acronym CAHAL. In total, we assessed 114 mothers and 82 fathers of 131 children, using the Pediatric Inventory for Parents, short form, General Health Questionnaire, Parental Stress Index-Short Form, State-Trait Anxiety Index and the Child Vulnerability Scale. Compared to the reference groups of the instruments used, parents of children with congenitally malformed hearts did not report higher generic nor disease-related stress scores, and parenting levels of stress were also comparable to reference groups. State anxiety levels, however, were higher in mothers of children with congenitally malformed hearts. Both fathers and mothers reported significantly higher rates of perceived vulnerability than did parents of healthy children. Risk factors for increased anxiety and perceived vulnerability were found in the number of surgical procedures, the time past since the last procedure, and ethnicity. Severity of the lesion did not influence parental levels of stress, but parents of children with hypoplastic left heart syndrome did report higher levels of stress than other parents. Psychosocial screening of parents of children with congenitally malformed hearts is important in order to provide appropriate counselling to those parents most in need.

Children subjected to cardiac surgery for congenital heart disease. Part 1 - emotional and psychological outcomes

This study investigated the psychological and emotional functioning of children with congenital heart disease (CHD) subjected to surgery. Children aged 2-12 years with CHD who underwent cardiac surgery were enrolled. Information was collected prior to surgery and 12 months or later following surgery. Measures included assessment of the child's receptive vocabulary, adaptive behaviour skills, emotional and behavioural development, temperament and parent quality of life, as well as surgical data. Similar information was collected from a control group prior to undergoing non-cardiac surgery. Of the 69 children contacted to enrol, completed pre- and post-surgical data were obtained from 39 children, and pre-surgical data from 12 controls. Children with CHD subjected to surgery displayed psychological and emotional functioning indistinguishable from normative populations or the control group. These findings persisted at reassessment 12-50 months after surgery. Psychological functioning at follow-up was most closely related to functioning prior to surgery. Significant residual defects and the need for further surgery were associated with poorer functioning. The results suggest an optimistic psychological and emotional outcome following cardiac surgery. This study may assist in identifying children most at risk of adverse outcomes after cardiac surgery and help guide therapeutic interventional programmes.

Quality of life and congenital heart defects: comparing parent and professional values

OBJECTIVE

To compare preferences obtained from health professionals with those from parents for the longer-term health outcomes of children with congenital heart defects.

SETTING

Cardiology conference; hospital.

PARTICIPANTS

109 paediatric cardiology professionals (72% female, median age 38 years) and 106 parents of children with congenital heart defects (82% female, median age 37 years).

INTERVENTIONS

Eight health state descriptions, for cardiac and neurological disability resulting from congenital heart defects, were developed and presented with a self-administered anonymous questionnaire. Respondents were asked to rank health state descriptions from best to worst, score each health state using a visual analog scale and mark death on this scale.

RESULTS

Health professionals and parents agreed in the order of ranking health states from best to worst. Both groups assigned the lowest scores to health states with severe neurological disability. Scores did not differ significantly by age, sex or whether the respondent was in the health professional or parent group. Of all respondents, 8% (17) scored at least one health state description worse than death.

CONCLUSIONS

Parents and health professionals place similar values on the quality of life outcomes of children with congenital heart defects. Both are more averse to health states describing worse neurological than cardiac disability. Improving our understanding of the relative importance of different outcomes to children and families is an important basis for sharing decisions about clinical care. The views of young people with congenital heart defects should be an important focus for future enquiry into health outcomes.

Fetal Diagnosis – Obligations of the Clinician

Fetal echocardiography allows for accurate diagnosis of major heart abnormalities by 16-18 weeks. The parents have up to 22 weeks to consider possible termination. What are the obligations of the clinician once an abnormality is found? Should only information be provided or is there a role in influencing the parents' decision? Two diverse examples are provided to discuss these questions. Mrs A., aged 40 years was noted at the 18-week and then the 20-week scan to have a fetus with a complete atrio-ventricular septal defect. In addition, the fetus had a Danny-Walker cyst. There was thickened nuchal folds and echogenic bowel all suggestive of a chromosomal abnormality. Amniocentesis was refused and the pregnancy continued. Mrs B., aged 34 years was noted at 19 weeks and again at 20 weeks to have a fetus with mild thickening of the walls of both the right and left ventricles. The flow patterns appeared normal. Despite a probable good outlook, the parents asked for a repeat scan at 22 weeks to allow them to consider possible termination. Despite a probable chromosomal abnormality, definite major cardiac and neurological abnormalities, Mrs A. refused karotyping and planned to proceed with the pregnancy. Mrs B., despite a probable good outcome for the fetus asserted pressure for us to prognosticate by 22 weeks. While non-directive counselling is the accepted norm, is that appropriate for all situations? Should one strongly influence Mrs A. to have an amniocentesis to confirm a probable Trisomy thereby allowing her to make a more informed decision? How reassuring can the clinician be to Mrs B. and if termination is sought should one counsel against that? Arguments for these positions are described, highlighting the difficulties faced by clinicians as they counsel parents often with incomplete information and in a setting of acute emotional distress.

Pre-natal counselling--helping couples make decisions following the diagnosis of severe heart disease

The prenatal diagnosis of a major cardiac abnormality tends to precipitate a crisis for the affected parents. In a setting of grief and emotional distress, there is the challenge to provide meaningful information of the abnormality, its need for intervention and likely outcome, so as to enable the parents, if allowed the option, to come to a fully informed decision as to whether to continue with the pregnancy. This discussion paper reviews the difficulties encountered in counselling affected parents being mindful of the psychological constraints prevalent at the time. While an accurate and detailed diagnosis is important for the professionals, the information required by the parents needs to be simple and focussed on the questions raised by them as they relate to quality of life issues to be experienced by their yet unborn infant/child growing into an adult.

Counselling Strategies in The Prenatal Diagnosis of Major Heart Abnormality

BACKGROUND

Prenatal diagnosis of a major cardiac abnormality precipitates a crisis in the parents. To their grief and/or anger may be added the burden of whether to continue with the pregnancy if the fetus is previable.

AIMS

We reviewed our counselling strategies to determine if the parents were satisfied with our approach and whether in their perception it provided the knowledge and understanding of the abnormality detected to help them in their decision.

METHODS

Questionnaires highlighting parental perception of their experiences, were developed and sent to a cohort of parents following the birth of their infant or at least 6 months after termination. The parents were seen over 3 years in a private obstetric ultrasound practice, diagnosed with or specifically referred because of the diagnosis of a major heart abnormality in the fetus, confirmed at a subsequent scan with the paediatric cardiologist in attendance. Both clinicians explained the abnormality, 'working off each other'. The obstetrician ensured the explanations were in lay terms. Anatomical detail, while important to the clinicians, was not emphasised, but rather function, quality of life issues and probable outcome and attendant risks of intervention. An appointment with the cardiologist was offered as was the need/option for further scans.

RESULTS

39 patients were reviewed, 13 of whom elected to terminate their pregnancy. Of the 30 who responded, 70% reported that the explanations of the abnormality were clear to very clear, whilst 85% considered the detail given was 'just right'. Only 60% rated their understanding of the diagnosis as 'good to excellent', improving to 80% with subsequent scans. These results were especially meaningful when 70% of the respondents described themselves as being distressed or very distressed following the initial diagnosis.

CONCLUSIONS

These results suggest that parents seemed satisfied with our approach of two clinicians working together emphasising function and outcome, rather than anatomical detail. Their perceived understanding seemed to allow them to make their decision concerning continuation or termination of their pregnancy.

Parental perception of small ventricular septal defects in childhood

OBJECTIVE

The main aim of this study was to determine the understanding and perception of parents following the diagnosis of a minor cardiac abnormality, namely a small ventricular septal defect, in the child. Other aims included discovering the reasons behind these perceptions and whether they affected the parents' management of their child and his/her cardiac problem.

METHODS

Fifty-six infants and children from two tertiary centres and the private practices of the participating cardiologists were enrolled over a 5-month period. Questionnaires were prepared and distributed to all their parents.

RESULTS

Complete data was obtained from 40 parents. Close to 80% of the parents perceived the small ventricular septal defect as a minor problem and most understood the nature of the defect. However, when asked about precautions for their child, only two-thirds recalled the need for antibiotic prophylaxis. Most parents experienced distress and anxiety when told initially of the diagnosis but none reportedly restricted their child's physical activity.

CONCLUSIONS

Most parents have a clear understanding and perception of their child's small ventricular septal defect. There is a need for further improvement to facilitate parental understanding, especially with regard to the need for antibiotic prophylaxis.

Developmental and behavioral status of infants and young children awaiting heart or heart-lung transplantation

OBJECTIVE

Research into cognitive development and behavior in children undergoing heart or heart-lung transplantation has focused mainly on older children, with investigation of children undergoing transplantation as infants or toddlers being largely retrospective. This study was conducted, therefore, to obtain pretransplant baseline measures of development and behavior for preschool-aged children.

METHODS

Children <3.5 years old were assessed before transplantation (n = 35) and compared with a group of children awaiting conventional cardiac surgery, a group undergoing bone marrow transplantation, and a group of healthy children. Development was measured by using the Ruth Griffiths Mental Development Scales, and behavior was measured with the Achenbach Child Behavior Checklist.

RESULTS

Within the transplant group, 17 had congenital heart disease (CHD), and 18 had cardiomyopathy (CM). Although the overall mean developmental scores were within the normal range for the transplant, conventional cardiac surgery, and bone marrow transplantation groups, scores were significantly lower than those of the healthy group. Within the transplant group, those with CHD had a significantly lower mean developmental quotient than those with CM. Furthermore, the CHD patients obtained significantly lower scores than those with CM on areas of development covering locomotor abilities, speech and hearing, eye-hand coordination, and performance.

CONCLUSIONS

In common with other groups of ill children, patients awaiting heart or heart-lung transplantation are at risk for developmental delay. Diagnosis is a salient factor in determining outcome in most areas of development. Psychosocial interventions need to be targeted to maximize developmental potential before transplantation.

Pregnancy termination following prenatal diagnosis of serious heart disease in the fetus

BACKGROUND AND AIMS

The fetal diagnosis of complex congenital heart disease (CHD) leads to a crisis for the affected couple. How much more so when a decision is made to terminate the pregnancy? In making that decision do the parents understand the anomaly, its consequences and possible outcome and does that information influence their decision process?

METHODS AND SUBJECTS

Questionnaires were developed. They were forwarded to parents seen in a private obstetric ultrasound practice, diagnosed with, or specifically referred, because of the diagnosis of a complex cardiac anomaly in the fetus. The diagnosis was subsequently confirmed by ultrasound examination in the presence of a paediatric cardiologist, in all but one patient. Once confirmed, both the obstetric ultrasonologist and cardiologist explained the anomaly, both working off each other, the obstetrician acting as the parent's advocate, asking and "demanding" explanations in lay terms, clarifying the nature of the anomaly, its possible consequences in the newborn and childhood, the need for intervention, and the short- and long-term risks, concentrating on quality of life issues. The parents were given the opportunity to meet with the cardiologist separately to clarify the diagnosis and management, before coming to a final decision to continue or terminate the pregnancy.

RESULTS

Over a 3-year period, 40 such patients were included in the study, of which 13 opted for termination. The anomalies were complex and included hypoplastic left heart syndrome, univentricular heart and atrioventricular septal defect. The three autopsies carried out confirmed the prenatal diagnosis. Completed questionnaires were received from nine couples, two being lost to follow up and two refusing to complete the questionnaire despite telephone contact. All nine responses stated the explanation given was "very clear" or "clear", the detail covered was "just right", and their understanding of the diagnosis was "good " to "excellent". Eight stated they were very distressed following the diagnosis, and seven experienced great difficulty in arriving at a decision. In contrast, two stated that the decision was "easy" or "very easy". The reasons for termination included concern for the welfare of the affected child, other siblings in the family and because of the distress of the parents themselves. Intellectual disability was given as an additional reason in the three who had associated chromosomal abnormalities.

CONCLUSIONS

Although the numbers were small, it would appear that the above approach used by an obstetric ultrasonologist and cardiologist, working together, explaining complex congenital heart disease in lay terms and focusing on the need for intervention, functional outcome and quality of life issues, provided the parents with a reasonable understanding of the anomaly. Nevertheless, the decision to terminate, very difficult for nearly all the couples, seemed to be based on the perceived distress of the affected infant/child, the siblings and parents themselves. While three couples were grateful for an opportunity to respond, two refused, suggesting the need for more detailed follow up and support for those parents who decide to terminate an apparently wanted pregnancy.

Parenting stress and children with heart disease

INTRODUCTION

Whereas the stress precipitated by the diagnosis of an infant's congenital abnormality is well recognized, this study examined parenting stress reported by parents of children older than 2 years with heart disease.

METHOD

Abidin's Parenting Stress Index was administered to parents of children ages 2 to 12 years with known heart disease during a cardiology outpatient clinic visit.

RESULTS

Parents of children with heart disease were more likely than the normative population to report excessive parenting stress, especially related to characteristics of the child that make them difficult to parent. Approximately 1 in 5 parents expressed clinically significant levels of stress. These parents expressed difficulty with setting limits or discipline of the child with heart disease. Parenting stress was not related to the severity of the child's heart disease, family socioeconomic status, or time since most recent surgery. Older age of the child was associated with higher parenting stress scores.

DISCUSSION

Clinicians must assess parenting stress at each health care visit to provide appropriate support and anticipatory guidance to families of children with heart disease.