Quality of Life, Depressed Mood, and Self-Esteem in Adolescents With

Heart Disease
MIRI COHEN, PHD, DANIELA MANSOOR, PHD, HAYA LANGUT, RN, BA, AND AVRAHAM LORBER, MD
Objective: To assess health-related quality of life (HRQoL), depressed mood, and self-esteem in adolescents with heart disease and
compare them with age-matched healthy adolescents (control group). Methods: Ninety adolescents (aged 12 to 18 years with
congenital or acquired heart disease) and 87 controls completed the HRQoL (TAAQOL-CHD), Center for Epidemiologic Studies
Depression scale, and Rosenberg self-esteem questionnaires. Relevant medical details were collected. The patients and their parents
were asked to rate their perceived severity of heart disease. Results: Adolescents with severe heart disease reported higher levels
of depressed mood and lower self-esteem than did adolescents with moderate and mild heart disease and age-matched healthy
controls. Adolescents with severe heart disease also reported worse HRQoL than those with moderate and mild disease. According
to the multiple regression analysis, 44% of variance of HRQoL was explained by the study variables. Disease severity alone
explained 11% of the variance, but when entered with the other study variables, depressed mood, self-esteem, and adolescents’
perceived severity of disease were the only significant contributors to the explained variance of HRQoL. An exploratory mediation
analysis, using the Sobel test, was therefore applied, and it showed that depressed mood and perceived disease severity, but not
self-esteem, mediated the relationship between disease severity and HRQoL. Conclusions: Lower HRQoL was found in
adolescents with severe heart disease. Psychosocial factors have a significant effect on the psychological state of adolescents, and
they should be addressed and treated. Key words: adolescents, health-related quality of life, heart disease, depressed mood,
self-esteem, perceived disease severity.

HRQoL ⫽ health-related quality of life.
INTRODUCTION
A dvanced diagnostic and therapeutic measures for congen-
ital and acquired heart disease have led to a larger pro-
portion of patients who reach adolescence and adulthood (1).
Patients, with structural congenital cardiac anomalies and
those with acquired heart dysfunction, vary in severity and are
often categorized into mild, moderate, and severe states. These
three categories of disease severity may have been a result of
surgical interventions or conservative therapy (2).
Living with heart disease has many psychosocial conse-
quences for adolescents (3). Previous studies reported higher
levels of psychological distress and behavioral problems
(4 –7) than those of healthy adolescents. Other studies reported
lower levels of psychological distress, or no difference com-
pared with control groups (8,9).
These contrasting reports raise the question of what factors
are related to higher psychological distress and worse psycho-
social adjustment in adolescents with heart disease. Possible
related factors may be cardiac status, health-related quality of
life (HRQoL), and personal factors such as self-esteem or
cognitive perceptions of disease severity.
Several studies found that increased severity of cardiac
problems was associated with either higher psychological
distress and behavioral problems (6,7,10,11) or no association
between severity of disease and psychological or behavioral
parameters (4).
From the Social Work Department (M.C., D.M.), Rambam-Health Care
Campus, Haifa, Israel; Pediatric Cardiology (H.L., A.L.), Meyer Children’s
Hospital, Rambam-Health Care Campus, Haifa, Israel; School of Social Work
(M.C.), Faculty of Social Welfare and Health Studies, Haifa University,
Israel; Bruce Rappaport Faculty of Medicine (A.L.), Technion, Haifa, Israel.
Address correspondence and reprint requests to Avraham Lorber, Pediatric
Cardiology, Meyer Children’s Hospital, Rambam-Health Care Campus,
Haifa, Israel. E-mail: a_lorber@rambam.health.gov.il
Received for publication March 20, 2006; revision received January 16,
2007.
DOI: 10.1097/PSY.0b013e318051542c
HRQoL focuses on functional limitations and their emo-
tional impact (12). Most studies reported that adolescents with
heart disease have a reduced HRQoL compared with healthy
adolescents (3,13) even after surgical correction for congenital
heart disease (14). On the other hand, Fekkes et al. (12) found
similar and even better HRQoL reported by adolescents and
adults with minor congenital heart disease than that of healthy
controls. Other studies found that the HRQoL of adolescents
with heart disease was not related to the severity of disease
(3). Participation in sports, which is an aspect of HRQoL, was
found to be related to higher self-esteem (15,16) but not to the
severity of disease (15).
Personal characteristics, such as self-esteem, and similar
constructs like self-concept and self-perception, are consid-
ered a personal resource that facilitates positive perceptions of
stressful life situations (17) and reduced psychological distress
(18 –21). Studies found lower self-esteem or self-concept in
patients with heart disease (10,22,23), although an improve-
ment in self-esteem was reported in children and adolescents
after heart surgery (24).
Cognitive perceptions of personal situations and the mean-
ing ascribed to them are subjective and differ among individ-
uals (17,25). The more negative or severe the perceptions are,
the higher the psychological distress found in individuals with
various diseases (17,26,27) and in adolescents and adults with
heart disease (28). Rietveld and colleagues (28) reported that
negative perceptions, but not severity of disease, were asso-
ciated with higher distress and worse psychological adjust-
ment.
Another factor that affect coping with illness is ethnicity,
although it was not previously assessed in relationship to
adolescents with heart disease. Previous studies suggested that
the more conservative Arab society tends to perceive illness
and disability as God’s will (29 –31), which may promote
acceptance and adjustment but may also increase passivity and
impede active coping.
Studies on adolescents with heart disease are sparse, and
often assess adolescents and adults together (28) or adoles-

Psychosomatic Medicine 69:313–318 (2007) 313

0033-3174/07/6904-0313
Copyright © 2007 by the American Psychosomatic Society
 M. COHEN et al.

cents with young children (3). The goals of this study were a) in comparison with their peers. The adolescents were asked to rate whether
to assess the level of HRQoL, depressed mood, and self- they engage in each activity more than their peers (⫽1), the same (⫽2), or less
(⫽3). They were asked to rate their school achievements in the same way.
esteem in adolescents with different levels of disease severity
(severe, mild, low) and in comparison with age-matched con-
trols; b) to identify relationships of cardiac and demographic Statistical Methods
variables, depressed mood, perceptions of disease severity, Descriptive statistics were used to examine the characteristics of the
and self-esteem, with HRQoL of adolescents with heart dis- sample. ␹2 analysis was used to assess differences in nominal variables.
Analysis of variance was used to assess differences between the study group,
ease; and c) to assess if perceived severity of heart disease, according to severity, and the control groups, followed by post hoc Scheffé
depressed mood, and self-esteem may mediate the relationship test to identify differences between pairs of groups. Correlations between
between severity of disease and HRQoL. study variables were assessed by Pearson and Spearman analyses. Multivar-
iate regression analysis was used to assess the contribution of study variables
METHOD to explain variance of HRQoL of the study group. Independent variables were
entered by means of the enter method in the following order: age, gender,
Participants and Procedure
ethnicity, severity of disease, perceived severity, depression, and self-esteem. The
The participants were 90 adolescents— 45 Jews and 45 Arabs, aged 12 to independent variables were entered simultaneously without exclusion of variables
18 years with congenital or acquired heart disease—followed up in the from the model. The Sobel test (37) was used to assess possible mediation
Pediatric Cardiology Department at the Rambam-Health Care Campus, Haifa. between disease severity and quality and life by depressed mood, perceived
Participants were recruited among patients who visited the clinic between severity of disease, and self-esteem. For the regression and mediation analysis,
March 2004 and October 2005, based on sampling on 1 working day per n ⫽ 90 proved sufficient according to the formula suggested by Green (38), using
week. The clinic’s visitors were distributed randomly throughout the week. Cohen’s (39) calculations of sample size based on power analysis, for large effect
The sample consisted of 11.5% patients, aged 12 to 18 years, at the clinic but size (R2 ⱖ 0.26). Levels of significance are shown in the tables. A probability
they constituted 64% of adolescents visiting on the recruitment days (1 day level of 0.05 was accepted as significant. All statistics are two-tailed analysis.
per week). Eighteen adolescents refused to participate or were unable to
answer the questionnaires due to communication problems, six did not com-
plete the questionnaire, and another 26 were not approached by the inter- RESULTS
viewer because of time constraints. Demographic Characteristics of the Study
The adolescents and their parents gave informed consent. The adolescents and Control Groups
answered the questionnaires, their parents were asked to rate their perception
of disease severity, and relevant medical data were collected. The control The groups were similar in the distribution of gender, father’s
group consisted of 39 Jews and 48 Arab healthy adolescents. The control education and employment, and adolescents’ level of religiosity
group constituted a convenience sample; they were approached in their (Table 1). The groups were age-matched (15.00 ⫾ 0.25 (mean ⫾
schools; and they and their parents gave informed consent. The study was standard deviation) for adolescents with heart disease and
approved by the hospital’s Ethics Committee.
15.02 ⫾ 0.28 for healthy adolescents). There were no differences
Questionnaires in demographic characteristics between children with congenital
and acquired heart disease (p ⬎ .05, data not shown).
Demographic data included age, gender, religion, father’s education and
employment, and religiosity. HRQoL was measured in the study group only
by the Netherlands Organisation for Applied Scientific Research Academic
Medical Centre Adult Quality of Life-Congenital Heart Disease questionnaire TABLE 1. Demographic Characteristics of Adolescents With Heart
(TAAQOL-CHD) (32), a cardiac-specific module of the generic HRQoL Disease and Healthy Adolescents
instrument. It contains three subscales: complaints or limitations during the
previous month, worries during the previous month, and burden of the Study Control
medical examinations. Only the 9-item complaints or limitations subscale was n ⫽ 90 n ⫽ 87
used (e.g., shortness of breath after strolling, feeling dizzy, looking pale). The Variables ␹2 (df)
other two were not used because of the length of the questionnaire and n % n %
because these variables were not directly assessed in the present study. Each
item consists of two questions. First, the frequency of occurrence of each Gender
complaint or limitation during the last month is scored on a 3-point scale (1 ⫽ Male 58 64.4 52 59.8 0.41 (1)
never; 2 ⫽ occasionally; 3 ⫽ often). If such problem occurred, the degree it Female 32 35.6 35 40.2
bothers the respondents is assessed on a 4-point scale (from 1 ⫽ not at all to Father’s education
4 ⫽ very much). The two scores are multiplied, and the final scores range Elementary 19 21.1 21 24.1 4.78 (2)
from 1 to 12; the higher the score, the worse is the HRQoL. Convergent and High school 42 46.7 27 31.0
discriminant validity showed satisfactory coefficients (32). In the present Academic 29 32.2 39 44.8
study, the internal reliability (Cronbach’s ␣) was 0.82. Fathers employed
Self-esteem was assessed by the Rosenberg self-esteem scale (33), a Yes 88 98.9 84 96.6 1.07 (1)
10-item measure of positive and negative aspects of self-esteem. The items No 2 1.1 3 3.4
were rated on a 4-point response scale (0 ⫽ strongly disagree to 4 ⫽ strongly Ethnicity
agree). Internal reliability (Cronbach’s ␣) was 0.60. Jewish 45 50.0 39 44.8 0.48 (1)
Depressed mood was assessed by the Center for Epidemiologic Studies Arab 45 50.0 48 55.2
Depression scale (34). A short (10-item) version was used; its validity was Religiosity
confirmed in previous studies (35); and it was found suitable for adolescents Secular 38 42.2 42 48.3 1.53 (2)
(36). Answers ranged from 1 (not at all) to 5 (very much). Internal reliability Mildly religious 37 41.1 41 47.1
(Cronbach’s ␣) was 0.82. Very religious 15 16.7 4 4.6
Degree of engagement in sports activity, watching TV, and playing/
chatting on the computer, and perceived school achievements were assessed df ⫽ degrees of freedom.

314 Psychosomatic Medicine 69:313–318 (2007)

QoL IN ADOLESCENTS WITH HEART DISEASE

TABLE 2. Health-Related Characteristics of Adolescents With Heart Disease (by Severity)

Severe Moderate Mild

n ⫽ 21 n ⫽ 27 n ⫽ 42
Variables
n % n % n %

Diagnosis (n ⫹ %)
Cyanotic 7 33.3 9 33.3 3 7.2 ␹2 (2) ⫽ 30.39**
Acyanotic 10 55.6 15 55.6 35 83.3
Acquired 4 11.1 3 11.1 4 9.5
Surgical intervention (n ⫹ %) 16 74.1 20 74.1 24 57.1 ␹ (1) ⫽ 3.24
Has a pacemaker (n ⫹ %) 4 0.0 0 0.0 1 2.4 ␹2 (1) ⫽ 9.68*
Receives medications (n ⫹ %) 16 51.4 14 51.4 7 16.7 ␹2 (1) ⫽ 15.33**
Quality of life (M ⫹ SD) 3.43 1.19 2.11 1.19 1.59 0.74 F(2,88) ⫽ 12.41**
Perceived severity—adolescent’s life (M ⫹ SD) 2.35 0.82 1.81 0.82 1.21 0.58 F(2,88) ⫽ 16.46**
Perceived severity—parents’ life (M ⫹ SD) 2.70 0.82 2.09 0.82 1.49 0.61 F(2,88) ⫽ 22.30**

M ⫽ mean; SD ⫽ standard deviation.

* p ⬍ .01; ** p ⬍ .001.

Health-Related Characteristics of Adolescents With
Heart Disease
Table 2 shows the distribution of disease-related variables
in adolescents with heart disease. Seventy-nine of the 90
adolescents had congenital heart disease, 19 were cyanotic,
and 60 were acyanotic. The acyanotic patients had predomi-
nantly moderate and mild disease. An additional 11 adoles-
cents had acquired heart disease: rheumatic disease (n ⫽ 6),
Kawasaki disease (n ⫽ 1), post myocarditis dilated cardiomy-
opathy (n ⫽ 1), and cardiac dysrhythmia (n ⫽ 3).
Sixty adolescents had had surgery. The post surgery time
varied. Adolescents with severe heart disease reported the
worst HRQoL, and those with mild disease reported the best
HRQoL (Table 2). The same differences between the three
groups were found for perceived severity of the disease by the
adolescents and their parents.
Health-related characteristics of adolescents with acquired
and congenital heart disease were compared. There was no
significant statistical difference between them in the percent-
age of adolescents with a pacemaker, but fewer adolescents
with acquired heart disease had undergone surgery (18.2%
versus 73.4% of the adolescents with congenital disease;
␹2 (1) ⫽ 13.26; p ⬍ .001) and more of them received medi-
cations (90.9% versus 34.2%; ␹2 (1) ⫽ 12.84; p ⬍ .001).
However, adolescents with acquired and congenital heart dis-
ease reported similar levels of HRQoL (p ⬎ .05).
Psychosocial Characteristics of the Study
and Control Groups
Table 3 shows that the adolescents with severe disease
were significantly more depressed and reported lower self-
esteem than adolescents with moderate and mild disease and
healthy adolescents, whereas no significant differences in
levels of depressed mood and self-esteem were found between
adolescents with moderate and mild disease and healthy ado-
lescents. Adolescents with severe and moderate disease par-
ticipated significantly less in sports than did adolescents with
mild disease and healthy adolescents. Adolescents with mild
disease and healthy adolescents were similar in their partici-
pation in sports. Time spent watching TV, computer games, or
chatting was similar across groups, and no significant differ-
ences were evident in school achievements.

TABLE 3. Psychosocial Variables for Adolescents With Heart Disease (by Severity) and for Healthy Adolescents

Severe Moderate Mild Control

Variable n ⫽ 21 n ⫽ 27 n ⫽ 42 n ⫽ 87 F(3,170)
Mean ⫾ SD Mean ⫾ SD Mean ⫾ SD Mean ⫾ SD

Depressed mood 2.16 ⫾ 0.95 1.62 ⫾ 0.70 1.55 ⫾ 0.61 1.66 ⫾ 0.50 4.14*a
Self-esteem 3.00 ⫾ 0.59 3.29 ⫾ 0.39 3.41 ⫾ 0.35 3.46 ⫾ 0.37 7.72**a
Sports activities 1.10 ⫾ 0.31 1.47 ⫾ 0.57 2.00 ⫾ 0.82 2.21 ⫾ 0.79 17.79**b
TV watching 2.05 ⫾ 0.69 2.06 ⫾ 0.76 1.81 ⫾ 0.52 1.79 ⫾ 0.60 2.06
Computer games/chatting 1.70 ⫾ 0.73 2.03 ⫾ 0.70 1.89 ⫾ 0.66 2.07 ⫾ 0.67 1.88
School achievements 2.50 ⫾ 1.23 2.09 ⫾ 0.82 2.16 ⫾ 0.93 2.06 ⫾ 0.79 1.40

SD ⫽ standard deviation.
* p ⬍ .01; ** p ⬍ .001.
a
According to the Scheffé test, significant difference was found between adolescents with severe heart disease and the other groups.
b
According to the Scheffé test, significant difference was found between adolescents with severe and moderate heart disease and the adolescents with mild heart
disease and healthy adolescents.

Psychosomatic Medicine 69:313–318 (2007) 315

 M. COHEN et al.

TABLE 4. Correlations Between Study Variables for Adolescents With Heart Disease

Variable 1 2 3 4 5 6 7 8 9 10

1. Age —
2. Gendera ⫺0.10 —
3. Ethnicitya 0.00 0.14 —
4. Severity ⫺0.12 0.15 0.16 —
5. Perceived severity— adolescents 0.15 ⫺0.15 0.02 0.41*** —
6. Perceived severity— parents 0.02 ⫺0.04 0.03 0.56*** 0.63*** —
7. Do sports ⫺0.15 0.09 ⫺0.23* ⫺0.46*** ⫺0.45*** ⫺0.45*** —
8. Quality of life 0.10 0.07 0.10 0.33** 0.50*** 0.31** ⫺0.34*** —
9. Self-esteem ⫺0.19 0.12 ⫺0.19 ⫺0.11 ⫺0.24* ⫺0.05 0.29** ⫺0.35*** —
10. Depressed mood 0.27* 0.16 0.15 0.32* 0.48*** 0.28** ⫺0.34** 0.47*** ⫺0.51*** —

* p ⬍ .05; ** p ⬍ .01; *** p ⬍ .001.

a
Spearman correlation.

Relationships Between Study Variables
Table 4 shows the correlation between the study variables.
Age, gender, and ethnicity were not significantly associated
with other study variables, except for sports activities, which
were significantly lower for the Arab adolescents. Severity of
disease was significantly and positively associated with ado-
lescents’ and parents’ perceptions of disease severity, and
negatively associated with participation in sports. Also, higher
disease severity was associated with worse HRQoL, depressed
mood, but not with self-esteem. Perceived severity by adoles-
cents and parents was associated with lower participation in
sports, worse HRQoL, and higher depressed mood, but only
adolescents’ perceived severity was associated with lower
self-esteem.
Multiple regression analysis was conducted to assess the
contribution of demographic and health-related variables, de-
pressed mood, and self-esteem for the explained variance of
HRQoL of adolescents with heart disease. According to the
regression model, 44% of the variance of HRQoL was ex-
plained by the study variables (adjusted R2 ⫽ 0.39; F(7,81) ⫽
9.72; p ⬍ .001). Perceived severity of the disease, higher
depression, and lower self-esteem were significantly related to
HRQoL. In the full regression model, disease severity was not
significantly associated with HRQoL, but when tested as sole
predictor of HRQoL, it explained 11% (r ⫽ 0.32; ␤ ⫽ 0.32;
t ⫽ 3.21; p ⬍ .001) of its variance. In addition, adolescents’
perceived severity and depressed mood correlated with
HRQoL (␤ ⫽ 0.54; t ⫽ 6.02; p ⬍ .0001 and ␤ ⫽ 0.47; t ⫽
4.94; p ⬍ .0001). Disease severity correlated with perceived
severity (␤ ⫽ 0.39; t ⫽ 3.93; p ⬍ .0001) and with depressed
mood (␤ ⫽ 0.33; t ⫽ 3.24; p ⬍ .001), so they could be
possible mediators of the association between disease severity
and HRQoL. When disease severity and depressed mood were
entered as predictors of HRQoL, with R2 ⫽ 0.27 (F(2,87) ⫽
16.14, p ⬍ .0001), ␤ for disease severity fell to 0.24 (t ⫽ 2.54;
p ⬍ .05), and ␤ for depressed mood was 0.42 (t ⫽ 4.45; p ⬍
.0001). The Sobel test (35) showed Z ⫽ 3.32 (p ⬍ .0001). The
same calculations were applied to disease severity and per-
ceived severity, with R2 ⫽ 0.31 (F(2,87) ⫽ 19.30; p ⬍ .0001),
and then ␤ for disease severity fell to 0.14 (t ⫽ 1.40; p ⬎ .05),
and ␤ for perceived severity was ⫺0.49 (t ⫽ ⫺5.04; p ⬍
.0001). The Sobel test showed Z ⫽ 3.14 (p ⬍ .001). Accord-
ingly, depressed mood and perceived disease severity were
factors mediating the effects of disease severity on HRQoL.
Self-esteem was also correlated with HRQoL (␤ ⫽ ⫺0.35; t ⫽
⫺3.50; p ⬍ .01) but was not significantly correlated with
severity of disease (␤ ⫽ ⫺0.07; t ⫽ ⫺0.64; p ⬎ .05) and,
hence, did not mediate the association between disease sever-
ity and HRQoL.
DISCUSSION
Our results demonstrate lower HRQoL and self-esteem
and heightened depressed mood among adolescents with
the more severe form of heart disease. Those with moderate
and mild states of disease were no different in these aspects
from matched healthy adolescents. However, when control-
ling for other study variables, severity of disease was not
related to HRQoL of the adolescents but to depressed
mood, self-esteem, and their own perception of disease
severity. In addition, perceived disease severity and de-
pressed mood might mediate the relationship between dis-
ease severity and HRQoL.
The finding that adolescents with moderate and mild
heart disease were similar in levels of depressed mood and
self-esteem to the healthy adolescents, in contrast to ado-
lescents with severe heart disease, supports previous find-
ings (7,10,11). However, the present study pointed to the
major role of depressed mood, perceived disease severity,
and self-esteem, but not the severity of disease itself, as
predictors of HRQoL. These findings are in accordance
with studies on adolescents with heart disease (3) and on
adolescents and adults with other chronic health problems
(40). The possible mediating role of depressed mood and
perceived severity of disease again accords with the cog-
nitive theories that regard cognitive perceptions and psy-
chological reaction as a link between disease consequences
and adjustment (17,41).
The present study provides an exploratory mediation effect
in adolescents with heart disease, which may make an impor-
tant contribution to our understanding of the processes of

316 Psychosomatic Medicine 69:313–318 (2007)

QoL IN ADOLESCENTS WITH HEART DISEASE
coping with heart disease in adolescents. Although self-esteem
was associated with HRQoL, it was not affected by disease
severity but rather by its subjective perception.
Another finding of the present study shows that adolescents
with severe and moderate heart disease are less active in sports,
which is in accordance with medical recommendations. In keep-
ing with reports on the benefit of sports activities to physical and
psychological health of adolescents, an effort should be made to
adjust exercise activity, rather than restricting activities.
The limitations of the present study should be noted. Al-
though the size of the study and control groups was large
enough to produce sufficient power analysis, larger groups
could contribute to the generalizability of study results. Also,
in the absence of data on rate of depression in the Israeli
adolescent population, the degree to which the present control
group is representative of adolescents in Israel is not known.
However, the demographics of the sample seem representative
of the Israeli adolescent population. Another weakness of the
study is that the surgery-related variables could not be as-
sessed in the regression and mediation analysis due to rele-
vance only to some of the study participants. In addition,
because adolescence is a time of immense changes and insta-
bility, a longitudinal design could improve information re-
garding the study variables and identify critical time points in
the passage from childhood to early and then to late adoles-
cence. A longitudinal study would also facilitate a more
definitive test of the mediation hypothesis. Multicenter col-
laboration is a means of increasing the number of participants
and further expanding our knowledge and understanding of
the emotional and psychological aspects of heart disease.
Furthermore, measures of sports and school achievements are
limited in the present study, and a more thorough investigation
of these variables should be conducted in future studies.
Nevertheless, the study bears important implications for the
treatment of adolescents with heart disease, particularly those
more severely affected. Psychosocial interventions should start
during childhood, with children and parents; such interventions
would reinforce the children’s coping abilities and prepare them
to contend successfully with the challenges they will later con-
front and enhance their HRQoL as adolescents.
REFERENCES
1. Lindberg L, Olsson AK, Jogi P, Jonmarker C. How common is severe
pulmonary hypertension after pediatric cardiac surgery. J Thorac Cardio-
vasc Surg 2002;123:1155– 64.
2. Perloff JK. Congenital heart disease in adults: a new cardiovascular
subspecificity. Circulation 1991;84:1881–90.
3. Krol Y, Grootenhuis MA, Destree-Vonk A, Lubbers LJ, Koopman HE,
Last BF. Health related quality of life in children with congenital heart
disease. Psychol Health 2003;18:251– 60.
4. Utens EM, Verhulst FC, Meijboom FJ, Duivenvoorden HJ, Erdman RA,
Bos E, Roelandt JT, Hess J. Behavioural and emotional problems in
children and adolescents with congenital heart disease. Psychol Med
1993;23:415–24.
5. Bjornstad PG. The impact of severe congenital heart disease in physical and
psychosocial functioning in adolescents. Cardiol Young 1995;5:56 – 62.
6. Gupta S, Giuffre RM, Crawford S, Waters J. Covert fears, anxiety and
depression in congenital heart disease. Cardiol Young 1998;8:491–9.
7. Janus M, Goldberg S. Treatment characteristics of congenital heart dis-
Psychosomatic Medicine 69:313–318 (2007)
ease and behavior problems of patients and healthy siblings. J Paediatr
Child Health 1997;33:219 –25.
8. DeMaso DR, Spratt EG, Vaughan BL, D’Angelo EJ, Van der Feen JR,
Walsh E. Psychological functioning in children and adolescents under-
going radiofrequency catheter ablation. Psychosomatics 2000;41:134 –9.
9. Salzer-Muhar U, Herle M, Floquet P, Freilinger M, Greber-Platzer S,
Haller A, Leixnering W, Marx M, Wurst E, Schlemmer M. Self-concept
in male and female adolescents with congenital heart disease. Clin Pediatr
2002;41:17–24.
10. Utens EM, Verhulst FC, Duivenvoorden HJ, Meijboom FJ, Erdman RA,
Hess J. Prediction of behavioural and emotional problems in children and
adolescents with operated congenital heart disease. Eur Heart J 1998;19:
801–7.
11. van Rijen EH, Utens EM, Roos-Hesselink JW, Meijboom FJ, van
Domburg RT, Roelandt JR, Bogers AJ, Verhulst FC. Longitudinal de-
velopment of psychopathology in an adult congenital heart disease co-
hort. Int J Cardiol 2005 18;99:315–23.
12. Fekkes M, Kamphuis RP, Ottenkamp J, Verips E, Vogels T, Kamphuis
M, Verloove-Vanhorick P. Health-related quality of life in young adults
with minor congenital heart disease. Psychol Health 2001;16:239 –50.
13. Moons P, Van Deyk K, Budts W, De Geest S. Caliber of quality-of-life
assessments in congenital heart disease: a plea for more conceptual and
methodological rigor. Arch Pediatr Adolesc Med 2004;158:1062–9.
14. Alden B, Gilljam T, Gillberg C. Long-term psychological outcome of
children after surgery for transposition of the great arteries. Acta Paediatr
1998;87:405–10.
15. Bar-mor G, Bar-tal Y, Krulik T, Zeevi B. Self-efficacy and physical
activity in adolescents with trivial, mild or moderate congenital cardiac
malformations. Cardiol Young 2004;10:561– 6.
16. Wind WM, Schwend RM, Larson J. Sports for the physically challenged
child. J Am Acad Orthop Surg 2004;12:126 –37.
17. Lazarus RS, Folkman S. Stress, appraisal and coping. New York:
Springer-Verlag; 1984.
18. Bednar R, Wells MG. Peterson SR. Self-esteem: paradoxes and innova-
tions in clinical theory and practice. Washington, DC: American Psycho-
logical Association; 1989.
19. Brage D, Campbell-Grossman C, Dunkel J. Psychological correlates of
adolescent depression. J Child Adolesc Psychiatr Nurs 1995;8:23–30.
20. Appleton PL, Ellis NC, Minchom PE, Lawson V, Boll V, Jones P.
Depressive symptoms and self-concept in young people with spina bifida.
J Pediatr Psychol 1997;22:707–22.
21. Kinney WB, Coyle CP. Predicting life satisfaction among adults with
physical disabilities. Arch Phys Med Rehabil 1992;73:863–9.
22. Kramer HH, Awiszus D, Sterzel U, van Halteren A, Classen R. Devel-
opment of personality and intelligence in children with congenital heart
disease. J Child Psychol Psychiatry 1989;30:299 –308.
23. Uzark K, VonBargen-Mazza P, Messiter E. Health education needs of
adolescents with congenital heart disease. J Pediatr Health Care 1989;3:
137– 43.
24. Wray J, Sensky T. How does the intervention of cardiac surgery affect the
self-perception of children with congenital heart disease? Child Care
Health Dev 1998;24:57–72.
25. Leung PWL, Wong MMT. Can cognitive distortions differentiate be-
tween internalizing and externalizing problems. J Child Psychol Psychi-
atry 1998;39:263–9.
26. Cohen M. Coping and emotional distress in primary and recurrent breast
cancer patients. J Clin Psychol Med Settings 2002;9:245–51.
27. Rietveld S, Brosschot JF. Current perspectives on symptom perception in
asthma: a biomedical and psychological review. Int J Behav Med 1999;
6:120 –34.
28. Rietveld S, Mulder BJ, van Beest I, Lubbers W, Prins PJ, Vioen S,
Bennebroek-Evererz F, Vos A, Casteelen G, Karsdorp P. Negative
thoughts in adults with congenital heart disease. Int J Cardiol 2002;86:
19 –26.
29. Neter E, Wolowelsky Y, Borochowitz ZU. Attitudes of Israeli Muslims at
risk of genetic disorders towards pregnancy termination. Community
Genet 2005;8:88 –93.
30. Yamey G, Greenwood R. Religious views of the ‘medical’ rehabilita-
tion model: a pilot qualitative study. Disabil Rehabil 2004;22;26:
455– 62.
31. Zahr L, Hattar-Pollara M. Nursing care of Arab children: consideration of
cultural factors. J Pediatr Nurs 1998;13:349.
32. Kamphuis M, Zwinderman KH, Vogels T, Vliegen HW, Kamphuis RP,
Ottenkamp J, Verloove-Vanhorick SP, Bruil J. A cardiac-specific
317

health-related quality of life module for young adults with congenital
heart disease: development and validation. Qual Life Res 2004;13:
735– 45.
33. Radloff LS. The CES-D scale: a self-report depression scale for research
in the general population. Applied Psychol Meas 1977;1:385– 401.
34. Rosenberg M. Society and the adolescent child. Princeton, NJ: Princeton
University Press; 1965.
35. Reback CJ, Brown VB, Huba GJ, Melchoir LA. A short depression index
for women. Educ Psychol Meas 1993;53:17–25.
36. Franko DL, Striegel-Moore RH, Bean J, Tamer R, Kraemer HC, Dohm
FA, Crawford PB, Schreiber G, Daniels SR. Psychosocial and health
consequences of adolescent depression in Black and White young adult
women. Health Psychol 2005;24:586 –93.
318
M. COHEN et al.
37. Baron RM, Kenny DA. The moderator-mediator variable distinction in
social psychological research: conceptual, strategic, and statistical con-
siderations. J Pers Soc Psychol 1986;51:1173– 82.
38. Green SB. How many subjects does it take to do a regression analysis?
Multivariate Behav Res 1991;26:499 –510.
39. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed.
New York: Academic; 1998.
40. Burker EJ, Evon DM, Sedway JA, Egan T. Appraisal and coping as
predictors of psychological distress and self-reported physical disability
before lung transplantation. Prog Transplant 2004;14:222–32.
41. Cohen M. First-degree relatives of breast-cancer patients: cognitive per-
ceptions, coping and adherence to breast self-examination. Behav Med
2002;28:15–22.
Psychosomatic Medicine 69:313–318 (2007)