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New study finds link between heart disease, and anxiety, depression, ADHD in kids

Dr. Chesney Castleberry, a pediatric cardiologist and medical director of the heart transplant program at Dell Children's Medical Center, listens to a patient's heart.  As part of the heart program, a pediatric psychologist also evaluates patients and families for risks of mental health problems.

Dr. Keila Lopez at Texas Children's Hospital in Houston knew based on other research that kids with chronic illnesses are disproportionally affected by mental health disorders. But what about patients in her field, pediatric cardiology?

Now she has some answers. She and other researchers analyzed the medical records of 118,785 pediatric patients ages 4 to 17, including 1,164 with congenital heart disease, and found that 18.2 percent of the kids with congenital heart disease had been diagnosed with anxiety, depression or attention-deficit hyperactivity disorder, compared with 5.2 percent of kids without heart disease.

The severity of the disease also mattered. Kids ages 4 to 9 with simple congenital heart disease were five times more likely than kids without heart disease to have a diagnosis; kids with more complex congenital heart disease were seven times more likely to have a mental health diagnosis. 

She also found that kids who were minorities or uninsured were less likely to have a mental health diagnosis regardless of the severity of their heart disease. She suspects they have less access to diagnosis or they are labeled "problem children" instead of "children with the disease process they have," Lopez says. 

Her research is published in the February issue of "Pediatrics." 

Dr. Keila N. Lopez is a pediatric cardiologist at Texas Children's Hospital in Houston.

Now that the numbers have been crunched, why would kids with heart disease have more mental health disorders? 

Some of it might be what happens in utero, she says. Were their forming brains exposed to less oxygenated blood because of their heart than kids without heart disease?

For some kids, the risk also could come with oxygen levels during surgeries. Dr. Chesney Castleberry, who is the medical director of the heart transplant program at Dell Children's Medical Center of Central Texas, also notes that kids who go on heart-lung bypass used during surgeries have a greater risk of depression. Kids with congenital heart disease also might have hormonal irregularities because of their livers not functioning normally. When kids are living in hospitals before or after surgeries, their days and nights can become confused, which also affects hormone levels. 

It also could be the level of anxiety and stress experienced by their parents, which then impacts the children's own mental health. And there could be genetic factors.

"There's a lot of association without obvious causations," Lopez says. 

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The research does tell pediatric cardiologists that their programs need to consider not just the heart, but the whole patient. That means being aware of the association between heart disease and mental health and screening for mental health disorders among their patients.

Lopez explains that the field of pediatric cardiology has developed from the initial goal being survival, and once patients were surviving, then worrying about the developmental delays and cognitive issues doctors were seeing. And then once those screenings and interventions were happening, worrying about the mental health aspects. 

"It's not just the recognition," Lopez says, "It's what are we going to do now."

Texas Children's has a dedicated cardiac psychiatrist in its program. Austin's Dell Children's, which has been building its congenital heart program, has a pediatric psychologist as part of the program.

"We are going to make this part of your child's plan," Castleberry says of mental health treatment. "When depression and anxiety does come, they have the tools in place... they have people they have an established relationship with, all in one place." 

The programs have social workers helping families with resources and child life specialists, who help kids prepare for procedures and help with quality of life inside the hospital. They also have neuropsychologist and neurologists looking for developmental delays and ADHD. 

Alexandra Lamari-Fisher is a pediatric psychologist in the congenital heart surgery department at Dell Children’s Medical Center and an assistant professor at Dell Medical School at the University of Texas at Austin.

Alexandra Lamari-Fisher is the pediatric psychologist at Dell Children's congenital heart surgery department. She does initial mental health screenings with children and families when they come into the program as well as goes on rounds while they are in the hospital. She uses the same notes system as the doctors involved in their care so they can see one another's notes.

One thing she's heard from her patients is they talk about heart disease being invisible. Unlike a child who is involved in an accident or who has cancer, a patient with heart disease might not look different than their peers, and other children might not understand why they can't keep up physically or in school. "They may laugh at them," she says. 

The kids also are dealing with their own mortality, their life being cut short or life-long medical concerns. 

"We address all of it," Lamari-Fisher says.

With parents she works on lessening their levels of anxiety. Research shows that parents who are dealing with their own anxiety — and there is a lot to be anxious about when you have a child with a life-threatening or chronic illness — can pass on that anxiety or post-traumatic stress disorder to their children. 

"Parents have a lot of guilt," Lamari-Fisher says. "'What did I do to cause this to my child?' You didn't do anything. It's sort of random at times, sometimes genetic, but more often than not it's not." 

She's also looking at the child for age-appropriate behavior and milestones. Sometimes because kids have been so sick, parents have been overly accommodating or done too much to help their children. That might mean the baby who never learns to crawl because she is held the whole time or kindergarteners who cannot self-regulate their emotions, or school-age kids who are impulsive or act out. 

"You can focus as much as you want in what's happening in a surgery ... but families and our peers shape us tremendously," Lamari-Fisher says. 'When kids get anxious and depressed, they refuse to take their medicine ... we've lost all the gains we've made."

Nicole Villalpando writes about health and pa for the American-Statesman. She can be reached at