Exploring the Effects of Psychosocial Interventions on Mental Status in Pediatric Congenital Heart Defects in a Tertiary Care Hospital in Pakistan

Exploring the Effects of Psychosocial Interventions on Mental Status in Pediatric Congenital Heart Defects in a Tertiary Care Hospital in Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Effects of Psychosocial Interventions on Mental Status in Pediatric Congenital Heart Defects in a Tertiary Care Hospital in Pakistan Vardah Noor Ahmed Bharuchi¹, Muneera Abdul Rasheed This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6653638/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Congenital heart defects (CHD) are structural heart malformations present at birth, often requiring early surgical interventions during critical developmental stages. Children with CHD are at risk for neurodevelopmental challenges, exacerbated by hospitalization and parental stress. This study evaluates the impact of psychosocial interventions during hospitalization on the mental status of pediatric CHD patients. Methods A quality improvement study was conducted in a tertiary care hospital in Karachi, Pakistan, from 2017 to 2019. The intervention utilized a Mental Status Examination Scale (MSE-S) to measure changes in mental status before and after psychosocial interventions. Purposive sampling included children aged 1 month to 6 years with CHD undergoing hospitalization. Descriptive analysis and paired samples T test were used. Results Significant improvements were observed in MSE-S scores across most CHD classifications. MSE-S scores in Single Ventricle group, increased from 37.46 (SD = 9.32) to 42.92 (SD = 12.6) (p = 0.018), while for Transposition of Great Arteries, scores rose from 35.77 (SD = 7.75) to 40.46 (SD = 8.61) (p < 0.001). The other 2-Ventricle group showed the largest improvement, from 32.43 (SD = 10.2) to 38.70 (SD = 9.21) (p < 0.001). Improvements were consistent in motor skills, speech, mood, and cognition subscales. Conclusion Psychosocial interventions during hospitalization significantly improve mental status of CHD children. These findings underscore the importance of developmental care and parental involvement in improving the mental and emotional well-being of pediatric patients. Further research with larger and diverse samples is warranted to generalize findings and explore long-term benefits. Congenital Heart Disease psychosocial intervention mental status paediatrics Introduction Congenital heart defects (CHDs) are known as structural malformations of the heart that are present at birth. The most common are the septal defects which constitute around 40% of CHD. Septal defects include atrioventricular and ventricular septal defects (VSD). The prevalence of CHD in Pakistan is 3.4 in 1000 and it is estimated that around 60,000 babies are born with CHD annually [ 1 ]. Approximately 80 patients born with CHD require at least one surgical intervention for complete or palliative cardiac repair [ 2 ]. The median age for CHD surgery is 1.2 to 1.9 years which is the critical age for development [ 2 – 4 ]. CHD can be classified according to the severity with most severe being single ventricle defect and the least severe being the arterial septal defect which includes partial anomalous pulmonary venous return (PAPVR). The details of the classification of CHDs are given in Table 1 . Table 1 Classification of CHDs CHD Type Description Single Ventricle This defect covers various cardiac structural abnormalities in which one structure is severely underdeveloped or no formation of ventricular septal wall. Due to anomalous structure, there is a mixing of oxygenated and deoxygenated blood. This occurrence is due to genetic factors, however environmental factors may also cause malformations [ 5 ]. Transposition of Great Arteries (TGA/VSD and DORV/TGA) Transposition of the great arteries (TGA), also known as transposition of the great vessels (TGV), is a common congenital heart defect that causes newborns to have a blue tint to their skin (cyanosis) within the first 24 hours of life. This condition occurs because the main arteries of the heart are switched: the aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. As a result, oxygen-rich blood is not circulated properly throughout the body. There are two main types of TGA based on the position of the aortic and pulmonary valves: L-loop TGA, where the heart has partially corrected itself, and D-loop TGA, which is more common and typically requires immediate medical intervention [ 6 ]. Other 2-Ventricle Infant Surgery (TOF, VSD, DORV) Double outlet right ventricle (DORV) is a rare congenital heart defect that a baby is born with. In this deformity the pulmonary artery and the aorta are connected to the right ventricle. In a normal heart, the pulmonary artery is connected to the right ventricle and the aorta is connected to the left ventricle. This deformity causes problem because the right ventricle carries oxygen-poor blood which is then circulated in the body [ 7 ]. The other heart condition, which is the ventricular septal defect (VSD) occurs with this deformity. VSD is the hole in the tissue wall (septum) which separates right from left ventricles. In VSD, oxygen rich blood is passed from left ventricle to aorta and pulmonary artery. Even though there is added oxygen, the body still does not get enough oxygen, which makes the heart work harder [ 7 ]. Arterial Septal Defects (ASD/PAPVR) The arterial septal defect (ASD) is the whole or a defect in the wall (septum) which separates the top two chambers of the heart which is atria. Because of this opening, the oxygen-rich blood leaks into the oxygen-poor blood chambers. If the ASD is large, the heart and lung work harder and the lung arteries become damaged [ 8 ]. The defects within the heart can be caused by issues in organ, environment and psychological issues of parents. The defects within the heart may affect cerebral development hence for pre-operative care, maximization of cerebral oxygen delivery and utilization is optimized [ 9 ]. Individuals with CHD can have impairment in motor, cognitive skills and language due to these reasons. They also have difficulty with state regulation and during feeding and sleep. Motor skill development is detected earlier among CHD children. This is caused by altered fetal brain development, white matter injury, hospitalizations and postoperative restrictions. Children who undergo surgeries are also at a greater risk for difficulties in adaptive functioning [ 10 ]. Patient specific, pre-operative factors and post-operative factors play a role in neurodevelopmental issues in these children. Some surgical and peri-operative factors that can cause neurodevelopmental issues in these children include seizures in infancy, cardiopulmonary resuscitation, mechanical support, heart transplantation and prolonged post-operative hospitalization in infancy. Post-operative hospitalization is a risk factor because of medical complications as well environmental issues such as simulation from bright lights, pain and noise. There is lack of positive stimulation along with maternal separation and oral feeding disruptions during hopsitalization. Other issues that can affect the development of these children include the symptoms of trauma in parents. Other psychological issues that can affect the growth of these children include parental depression, anxiety and severe psychological distress [ 10 ]. Children who undergo surgeries earlier in life with admission in intensive care, painful medical procedures, lengthy hospitalizations and separation from attachment figures can have typically mild development effects, however if these go undetected it can become complex [ 11 ]. However, with the improvements of survival rates among newborn, the focus have now changed to neurodevelopmental outcomes for these children across their life span. Preventive measures have been utilized for adverse neurodevelopmental outcomes. One of the interventions is developmental care. Developmental care includes external stimuli control such as auditory, visual, tactile and vestibular stimulation as well as understanding the infant behavioural cues. Other interventions that can help infants include increased participation of parents for the care of their children which can reduce parental anxiety and improve infant neurodevelopment. Habilitative services such as physical, occupation and speech-language therapies can help when timely interventions are given [ 10 ]. Even though benefits of offering interventions before and after hopsitalization have been observed, there is a research gap in understanding the immediate and long-term benefits of providing interventions during hospitalization to CHD patients. Studies in the last decade have shown that early interventions, such as developmental care and increased parental involvement, can positively influence neurodevelopmental outcomes in children with chronic health conditions. Studies by Godino-Ianez et al. (2020) indicate that targeted interventions during hospitalization can mitigate some of the adverse effects associated with prolonged medical treatment and hospitalization. Such adverse effects include negative emotions and behavior and other side-effects [ 12 ]. However, research specifically targeting children with CHDs is limited. The present study builds on these findings by focusing on a broader range of developmental domains and examining immediate effect. The psychosocial interventions can impact motor skills, speech, communication, mood and affect, cognition, play and interpersonal relationships. These components can be used to understand the mental status of infants and toddlers with CHD. Mental status examination is comprised of functional and cognitive status. Cognitive status includes attention, memory, information processing and functional status includes dependency, physical weakness (such as motor movement) and adaptive functioning [ 13 ]. The present study aims to see whether psychosocial interventions related to motor skills, cognitive skills, emotional and social and language skills during hospitalization will lead to significant improvements in the Mental Status Examination Scale (MSE-S) scores across various domains for pediatric patients with CHD and if it varies by types of CHD. Methodology Study Setting and Design This study employed an implementation focused research design in a play stimulation intervention conducted in the pediatric ward of a private hospital in Karachi, Pakistan, using purposive sampling from November 2017 to December 2019. This study was part of a bigger study, and details can be found in Rasheed et al. (2021) [ 14 ]. The cardiology pediatric ward comprises of one unit with a total of 6 beds. There were 4 beds in the cardiac intensive care unit (CICU) and 6 beds in special care unit. The hospital serves patients from across Pakistan as well as neighboring countries, including Afghanistan, Iran, and Iraq, and caters to individuals from various socio-economic backgrounds. Ethical approval for the study was obtained from the institute’s Ethical Research Committee. Implementation Strategy for the Intervention In the initial phase of the study, a theory of change model was developed with the aim of reducing stress for children and their families during hospitalization [ 14 ]. This model identified both internal and external resources and informed the creation of a comprehensive intervention package. This package included an intervention manual designed for children aged one month to six years, featuring activities targeting cognitive, socio-emotional, language, and motor skills (both fine and gross). Additionally, the package comprised behavioral observation forms for both parents and children, as well as a mental status examination form for children. Parental feedback was collected during the final session. Training manuals for nurses and psychology students were also developed, with student performance evaluated using a supervision observation checklist that assessed skills in active listening, core therapeutic conditions, and the application of interventions. A summary of the intervention package is provided in a separate manuscript [ 14 ]. The trainees (psychology students) provided therapy on bedside and aided the caregivers in offering stimulation to their children. Each session would last between the 20 to 40 minutes and students would observe the mental status of children before and after the intervention. Data Collection Measure Mental Status Examination Scale (MSE-S) The Mental Status Examination Scale (MSE-S) includes demographic information and evaluates several domains, including motor skills, communication, mood, and attention, both before and after the session. The scale features a variety of question formats: multiple-choice questions for aspects such as session transitions and play themes [ 15 ], dichotomous questions for orientation to person, place, and time, and multiple-response questions for mood and session transitions [ 15 ]. The total score ranges up to 60. The higher the score the better the mental status of the child would be. Domains assessed by the scale include general appearance, motor skills, speech, communication, mood and affect, orientation, thought content, insight and judgment, and interactions with caregivers and therapists. The scale utilizes a combination of rating and branching questions [ 16 ]. For a comprehensive description of the scale, refer to Bharuchi & Rasheed, 2021 [ 13 ]. Data Collection Procedures, Management, and Analysis This study focused on children who received therapy, with interventions constrained by limited resources, meaning not all children in the ward could be included. Therapy was provided based on paediatric cardiologists’ recommendations or identified by trainees at the bedside. Consent was obtained from caregivers, nurses, and residents. Selection criteria included the child's age, sleep status, and any upcoming procedures, leading to purposive sampling. Sample size calculations were not conducted as this was a quality improvement initiative [ 14 ]. Data were collected by trainees before and after the intervention, with sessions conducted by caregivers when possible. In cases where caregivers were unavailable due to consultations or breaks, trainees performed the sessions with prior permission from bedside nurses or residents. Observations included the child’s movements, interactions with caregivers, and engagement in play. Each intervention session lasted between 20 to 40 minutes, depending on the child’s age, with shorter sessions for younger children. Caregivers were instructed on the activities and encouraged to participate. Children were assessed using the Mental Status Examination Scale (MSE-S) based on their behavior and responses during the intervention. Data from the MSE-S were collected via Google Forms and subsequently compiled in Microsoft Excel. The data were cleaned, cross-checked with discharge summaries from the hospital's online portal, and numerically coded by the first author. The classification of CHD into different types and severity was further done via consulting an experienced researcher in neurodevelopmental outcomes of children with CHD. The CHD types were identified as single ventricle defect, transposition of great arteries, other 2-ventricle infant surgery, arterial septal defects, CHD with genetic condition and other cardiac conditions. CHD was classified according to the severity with most severe being single ventricle defect and the least severe being the arterial septal defect which includes partial anomalous pulmonary venous return (PAPVR). The details of the classification of CHDs are given in Table 1 . Descriptive statistics summarized the quantitative data. Frequencies and mean were analyzed using IBM SPSS for MSE-S subscale scores. Paired samples t-tests examined changes in MSE-S scores before and after the intervention across CHD types. Results Table 2 shows the descriptive analysis of CHD disease type with gender, age group, number of sessions and length of stay. Most of the children had Other 2-Ventricle Infant Surgery (TOF, VSD, DORV). The details of the disease type are given in Table 1 . Children who had other procedures were children undergoing procedures like right heart catheterization. Participants were distributed across various CHD classifications, with Other 2-Ventricle being the most common (41.42%), followed by TGA (20.91%) and Single Ventricle (7.69%). Males were predominant in most groups, especially in Single Ventricle (69.23%). Most participants were aged 4–6 years, though newborns were more common in ASDs (41.67%) and Cardiac Conditions (50.00%). Most attended one session, with fewer attending multiple sessions. The average hospital stay was longest for TGA (22.47 days) and shortest for Other Procedures (3.00 days). Table 2 Descriptive Statistics Demographics CHD Classification Single Ventricle TGA Other 2-Ventricle ASDs Other Procedures Cardiac Conditions With Genetic Conditions N(%) 13 (7.69) 35 (20.91) 70 (41.42) 12 (7.10) 3 (1.78) 14 (8.28) 9 (5.33) Gender (N(%)) Male 9 (69.23) 19 (54.29) 32 (45.71) 8 (66.67) 1 (33.33) 9 (64.29) 6 (66.67) Female 4 (30.77) 16 (45.71) 38 (54.29) 4 (33.33) 2 (66.67) 5 (35.71) 3 (33.33) Age Group (N (%)) Newborns – 6 months - 6 (17) 13 (18.57) 5 (41.67) 1 (33.33) 7 (50.0) 3 (33.33) 7–12 months 4 (30.77) 4 (11.43) 19 (27.14) - 1 (33.33) 1 (7.14) 1 (11.11) 13–24 months - 3 (8.57) 12 (17.14) 2 (16.67) - 3 (21.43) - 2–3 years 1 (7.69) 5 (14.29) 11 (15.71) 3 (25.0) - - 4 (44.44) 4–6 years 8 (61.54) 17 (48.57) 15 (21.43) 2 (16.67) 1 (33.33) 3 (21.43) 1 (11.11) Session (N (%)) 1 8 (61.54) 19 (54.29) 38 (54.29) 10 (83.33) 2 (66.67) 7 (50.0) 7 (77.78) 2 2 (15.38) 5 (14.29) 23 (32.86) 2 (16.67) 1 (33.33) 5 (35.71) 2 (22.22) 3 2 (15.38) 4 (11.43) 5 (7.14) - - 1 (7.14) - 4 1 (7.69) 1 (2.86) 1 (1.43) - - 1 (7.14) - 5 and more - 6 (17.14) 3 (4.29) - - - - Length of Stay (M (SD)) 15.85 (9.33) 22.47 (23.71) 12.24 (9.24) 5.67 (2.71) 3 (1.15) 9.71 (2.89) 14.33 (13.63) Table 3 shows a series of paired samples t-tests were conducted (Table 3 ) to compare the Mental Status Examination Scale (MSE-S) scores before and after the intervention across different categories of congenital heart disease (CHD). For patients with single ventricle conditions, there was a significant decrease in MSE-S scores from before the intervention (M = 37.46, SD = 9.32) to after the intervention (M = 42.92, SD = 12.6), t(12) = 2.72, p = .018, 95% CI [9.83, 1.09], with a mean difference of 5.46 (SD = 7.23). For patients with transposition of the great arteries (TGA), there was a significant decrease in MSE-S scores from before (M = 35.77, SD = 7.75) to after the intervention (M = 40.46, SD = 8.61), t(34) = 5.9, p < .001, 95% CI [6.3, 3.07], with a mean difference of 4.69 (SD = 4.7). For patients who underwent other 2-ventricle infant surgeries, there was a significant decrease in MSE-S scores from before (M = 32.43, SD = 10.2) to after the intervention (M = 38.7, SD = 9.21), t(69) = 9.96, p < .001, 95% CI [7.53, 5.02], with a mean difference of 6.27 (SD = 5.27). For patients with atrial septal defects (ASDs), the decrease in MSE-S scores from before (M = 29.75, SD = 15.04) to after the intervention (M = 33.83, SD = 13.48) was not statistically significant, t(11) = 2.06, p = .064, 95% CI [8.46, 0.29], with a mean difference of 4.08 (SD = 6.88). For patients who underwent other procedures, there was a significant decrease in MSE-S scores from before (M = 27.33, SD = 10.6) to after the intervention (M = 33, SD = 12.12), t(2) = 6.43, p = .023, 95% CI [9.46, 1.87], with a mean difference of 5.67 (SD = 1.53). For patients with other cardiac conditions, there was a significant decrease in MSE-S scores from before (M = 30.93, SD = 11.23) to after the intervention (M = 36.79, SD = 11.4), t(13) = 3.82, p = .002, 95% CI [9.17, 2.55], with a mean difference of 5.86 (SD = 5.74). For patients with genetic conditions, there was a significant decrease in MSE-S scores from before (M = 29.89, SD = 12.14) to after the intervention (M = 36.78, SD = 12.85), t(8) = 3.62, p = .007, 95% CI [11.28, 2.5], with a mean difference of 6.89 (SD = 5.71). Table 3 Paired Samples T Test of Categories of CHD and score on MSE-S Classification N Before After Mean Standard Deviation Mean Standard Deviation t df Sig Single Ventricle 13 37.46 9.32 42.92 12.6 2.72 12 0.018 TGA 35 35.77 7.75 40.46 8.61 5.90 34 0 Other 2-ventricle infant surgery 70 32.43 10.2 38.7 9.21 9.96 69 0 ASDs 12 29.75 15.04 33.83 13.48 2.06 11 0.064 Other procedures 3 27.33 10.6 33 12.12 6.43 2 0.023 Cardiac conditions 14 30.93 11.23 36.79 11.4 3.82 13 0.002 With Genetic Conditions 9 29.89 12.14 36.78 12.85 3.62 8 0.007 Missing 10 34 12.38 42.6 8.29 3.29 9 0.009 Table 4 presents the mean scores for the MSE-S subscales before and after the intervention across different classifications. Overall, improvements were observed in several domains following the intervention. Single Ventricle: There were notable improvements in motor skills (mean increased from 5.44 to 6.00) and play observation (mean increased from 5.46 to 6.85). Communication, mood, and affect showed minor changes, with stable scores in general appearance. TGA: Motor skills improved moderately (mean increased from 4.26 to 4.83), while slight increases were seen in communication and mood/affect. Scores for play observation remained consistent. Other 2-ventricle infant surgeries: Improvements were observed in motor skills (mean increased from 4.60 to 4.93) and play observation (mean increased from 4.64 to 6.57). Communication and mood scores increased modestly. ASDs: Motor skills and play observation scores improved (mean increased from 4.57 to 4.71 and from 5.45 to 6.64, respectively). Mood and communication domains showed minor increases. Other procedures: Scores for play observation increased (mean increased from 4.33 to 7.00), while other domains, such as general appearance and motor skills, remained relatively unchanged. Cardiac Conditions: Improvements were noted in motor skills (mean increased from 4.00 to 5.33) and play observation (mean increased from 5.50 to 6.57). Communication and mood showed slight improvements as well. With Genetic Conditions: Moderate improvements were observed in play observation (mean increased from 5.22 to 6.22) and cognition (mean increased from 8.00 to 10.67). Table 4 Mean Scores before and after the intervention of MSE-S subscales Classification General Appearance Motor skills Speech Communication Mood & affect Cognition Play Observation Interpersonal Relationship N Mean (SD) Mean (SD) Before Mean (SD) After Mean (SD) Before Mean (SD) After Mean (SD) Before Mean (SD) After Mean (SD) Mean (SD) Mean (SD) Before Mean (SD) After Mean (SD) Single Ventricle 13 4.69 (1.11) 4.31 (1.89) 5.44 (0.88) 6 (0) 3.3 (0.82) 3.3 (0.95) 5.46 (2.11) 6.85 (1.68) 11.08 (3.38) 10.23 (1.96) 7.46 (2.82) 7.38 (2.81) TGA 35 4.57 (1.24) 3.57 (1.72) 4.26 (1.45) 4.83 (1.5) 2.6 (1.25) 2.85 (1.06) 2.6 (1.25) 2.85 (1.06) 11.49 (2.95) 9.86 (2.21) 7.31 (2.36) 8.23 (2.44) Other 2-ventricle infant surgery 70 4.53 (1.15) 3.56 (1.77) 4.6 (1.52) 4.93 (1.52) 2.27 (1.47) 2.53 (1.31) 4.64 (1.99) 6.57 (1.8) 9.2 (3.75) 9.93 (2.47) 7.03 (2.73) 7.3 (2.91) ASDs 12 4.92 (0.9) 3.42 (1.73) 4.57 (1.62) 4.71 (1.7) 2 (1.77) 2.63 (1.6) 5.45 (2.07) 6.64 (1.8) 8.82 (4.62) 9.75 (2.83) 6.2 (3.33) 7.09 (3.42) Other procedures 3 5.33 (0.58) 5.33 (1.15) 6 (0) 6 (0) 3.17 (0.98) 3.13 (1.13) 4.33 (3.51) 7 (1.73) 4.67 (2.08) 11.67 (0.58) 9.5 (0.71) 7 (4.24) Cardiac conditions 14 4.29 (1.44) 3.14 (2.32) 4 (1.55) 5.33 (1.63) 1.78 (1.09) 2.67 (1.32) 5.5 (2.59) 6.57 (2.14) 10.93 (1.59) 10.93 (1.59) 7.57 (3.03) 8.14 (2.71) With Genetic Conditions 9 4.67 (1) 2.25 (1.98) 4 (2.08) 4.29 (1.8) 2.25 (1.39) 2.63 (1.06) 5.22 (2.82) 6.22 (2.59) 8 (4.39) 10.67 (1.5) 6.33 (1.8) 8.22 (2.39) Missing 10 4.8 (1.4) 2.5 (1.78) 5.67 (0.82) 5.71 (0.76) 2 (0) 2 (0) 5.2 (1.93) 6.9 (1.37) 10.7(3.56) 9.6 (2.46) 8.25 (2.96) 9.4 (1.58) Discussion Overall significant difference in mean on MSE-S was observed before and after intervention for all classifications of CHD except for ASDs. This proves the hypothesis that interventions had a significant impact on the mental status of infants and toddlers with CHD. It has been found out that spiritually sensitive interventions can decrease the depressive symptoms of hospitalized children with CHD [ 17 ]. Nursing interventions (education and empathic interviewing, therapeutic play interventions and motor exercise) in perioperative stage have been found to reduce the complication and pain in the post-operative stage which led to reduced length of stay [ 18 ]. A significant difference before and after the intervention was not observed in children with ASD. One reason could be because these children may not have been psychologically affected as much as the children with other conditions as ASD is not as severe as the other conditions [ 19 ]. This can be further supported by a study that was conducted that showed that the scores on the health-related quality of life of ASD children was similar to control group children without heart defects [ 19 ]. Other factors that can also impact the mental status could be parental stress, parental involvement, time of intervention and duration of hospital stay [ 19 ]. When subscales of MSE-S were investigated, different scores were observed for different conditions. For motor skills, CHD children with genetic conditions scored the lowest in the present study. Around 30% of the children with CHD have underlying genetic anomaly that can lead to worse neurodevelopmental outcomes including motor delays as compared to children with CHD but without genetic conditions [ 20 ]. The time of surgery such as whether the child received surgery at an earlier age as compared to later age also impacts the motor skills. Other factors for poor motor skills include oxygen saturation level below 85% and immobilization after surgery [ 21 – 23 ]. The age of the child can also be a cause for poor motor skills as studies have found out that the prevalence of abnormal motor development is highest between 0 to 12 months and the prevalence seems to decrease in the months of 12 to 24 months and it decreases further when the child is 24 to 36 months old [ 20 ]. This can explain the difference in the motor skills score in different categories of CHD. One subscale of MSE-S was speech which was measured by looking at the child’s frequency of saying words and babbling as well as the volume [ 13 ]. Children from all categories of CHD scored above 4 out of the total score of 6 before and after intervention. Children post-surgery are at risk for developing vocal cord palsy and children with genetic conditions are more at risk for developing this condition [ 24 ]. Motor delays also play an important role in speech production [ 20 ]. Children with CHD have delays in babbling, first-word production, two-word sentences, etc. However, to improve the quality-of-life early family counselling and language therapy are recommended [ 25 ]. With subscale of speech, communication was also measured. The score on communication domain was measured via assessing receptive language and expressive language such as instruction following and age-appropriate speech, was almost the same before and after the intervention. The total score was out of 4 and in most categories of CHD, infants and toddlers scored above 2. Children with CHD have lower receptive and expressive language skills as compared to children without CHD [ 26 ]. However, a study on 22 months old toddlers found out that stimulating home environment of CHD children can improve cognitive and language outcomes [ 27 ]. Children who took part in the follow-up neurodevelopment and intervention programs reported to have better language and communication outcomes [ 28 ]. Hence, if interventions are introduced during hospitalization, it can benefit CHD children in speech and language development. Most of the children scored above 4 out of the total score of 8 on the subscale of mood and affect before the intervention and above 6 after intervention. Children with TGA had an average score of 2.60 and 2.85 after intervention. Psychosocial interventions play a significant role in the mood and affect of chronically ill children [ 29 ]. Studies have also found out that psychosocial stimulation improves the immune system function [ 30 ]. The low score on mood and affect of children with TGA can be explained by chronic post-operative complications and perinatal impaired cerebral oxygen delivery [ 31 ]. Survivors of TGA are at increased risk for developing ADHD, anxiety and depression [ 31 , 32 ]. Cognition is another subscale from MSE-S. The total score was out of 15 and the subscale measures attention, orientation, intelligence and thought content. The lowest score was obtained by CHD children with genetic conditions and ASDs followed by other 2-ventricle infant surgery. Children from other categories scored above 10. In a study that was conducted on children it was found out that scores of cognitions were dependent on when the child had surgery [ 33 ]. In another study it was found out that individuals with simple congenital heart defect have a higher symptom of ADHD [ 34 ]. Interventions in follow-up appointments related to attention and cognition can improve these functions [ 35 ]. Play observation is another component of MSE-S. It measures whether the theme of play, type of play and transition out of the session is positive or negative. The total score is out of 15 and average score of children from all categories was above 9 which shows that the play was mostly positive. Studies on chronically ill children have shown that play has positive impact and improves symptoms of depression and self-concept [ 29 ]. Non-pharmacological interventions such as play and other psychosocial interventions can help in reducing the symptoms of pain as well as caregivers’ anxiety, distress and trauma symptoms [ 36 ]. Play and psychosocial interventions can be used with CHD children to enhance positive mood as well as self-concept. The MSE-S measured the interpersonal relationship with caregivers and trainees before and after the sessions. Children from most categories scored above 7 before and after intervention except for children with ASD and CHD with genetic condition. Children with genetic condition may have scored low due to challenges with genetic disorders as these children are more susceptible to neurodevelopmental issues. Children with CHD have difficulties in social and behavioural development which can lead to externalizing and internalizing behaviour issues [ 11 ]. Maternal-fetal bonding can enhance interpersonal relationship as well as the sensitivity and responsiveness of parents while interacting with their child after the diagnosis. Maternal anxiety is related to interpersonal relationship. Parental involvement with the child can impact emotional health of the child. It is has been found out that some parents after receiving the diagnosis are not as responsive and may withdraw in adequate caregiving [ 37 ]. Caregiver interaction at the time of diagnosis and hospitalization for CHD children can improve the psychological outcomes which includes interpersonal relationships. This study has several limitations. First, the sample size was relatively small, and the study was conducted in a single pediatric ward of a private hospital in Karachi, Pakistan. This limits the generalizability of the findings to other settings and populations. Second, the study utilized purposive sampling, which may introduce selection bias and affect the representativeness of the sample. Third, due to the constraints of limited resources, not all children in the ward could be included in the intervention, potentially influencing the outcomes. Additionally, the study did not conduct sample size calculations as it was part of a quality improvement initiative, which may impact the statistical power of the findings. Furthermore, the intervention sessions varied in length and caregiver participation, which could have influenced the consistency of the intervention's effects. The reliance on caregiver and trainee observations for data collection may also introduce observer bias. Lastly, the study did not account for potential confounding variables such as the severity of the cardiac condition, the child’s pre-existing developmental status, and the duration of hospital stay, which could affect the outcomes. Conclusion The findings of this study indicate that psychosocial interventions during hospitalization are associated with improvements in Mental Status Examination Scale (MSE-S) scores across various domains for pediatric patients with congenital heart defects (CHD). Significant improvements were observed in overall MSE-S scores, as well as in subscales measuring motor skills, speech, communication, mood and affect, cognition, play observation, and interpersonal relationships. These results highlight the potential benefits of incorporating developmental care and increased parental involvement during hospitalization to enhance neurodevelopmental outcomes in children with CHD. However, the limitations of this study suggest the need for further research with larger, more diverse samples and controlled study designs to confirm these findings and understand the long-term impacts of such interventions. Future studies can also consider the role of additional factors such as the severity of the condition, pre-existing developmental status, and hospital stay duration in influencing outcomes. Declarations The authors have no competing interests to declare that are relevant to the content of this article. Human Ethics and Consent to Participate This study was part of a broader transformative initiative undertaken by the Children’s Hospital of The Aga Khan University. At the time of admission, caregivers were informed about the initiative, and general consent was obtained. Specific consent for this service was waived, as it was included in the standard consent procedure prior to hospitalization. Verbal consent was sought from caregivers before the interventions from this study were given. Ethics Approval: This study was part of a larger quality improvement initiative aimed at enhancing patient experience in the Paediatric Service Line, approved by the Ethics Review Committee of The Aga Khan University. For this study, Ethical approval was granted by Dr. Jamsheer Talati, Chair of the Ethics Review Committee. The ERC approval number is 4778-Ped-ERC-17. All procedures followed the ethical standards outlined in the Declaration of Helsinki. Clinical trial number not applicable. Funding : The project was funded by Aga Khan University’s Children’s Hospital. Author Contribution V.B.: data curation (lead), formal analysis (lead), investigation (supporting), methodology (equal), project administration (equal), writing- original draft (lead). M.R.: conceptualization (lead), investigation (lead), methodology (equal), project administration (equal), resources (lead), supervision (lead), writing -review and editing (lead). Acknowledgement We extend our heartfelt gratitude to Dr. Babar Hasan for his unwavering support throughout this study. We also sincerely thank Dr. Adam Cassidy for his invaluable guidance in writing this manuscript. Additionally, we acknowledge the contributions of the students from the Institute of Professional Psychology, Bahria University, whose efforts were instrumental in this research. Data Availability Data can be available upon request to the principal investigator (PI) of the study. The PI can be contacted via: [email protected] References Syed Irtiza Ali, Obaid Yusuf Khan, Naveed N, Ahmad H, Patel N, Arif A (2024) Congenital septal defects in Karachi, Pakistan: an update of mutational screening by high-resolution melting (HRM) analysis of MTHFR C677T. Hum Genomics 18(1) Zahid I, Tariq M, Hashmi S, Amanullah M, Shahabuddin S (2021) The Glenn procedure: Clinical outcomes in patients with congenital heart disease in Pakistan. Ann Card Anaesth 24(1):30 Nakayama Y, Horimoto Y, Suzuki K, Takiguchi M, Ishihara K, Umehara N, et al. (2024) Clinical course of residual ventricular septal defects after congenital heart disease repair. Pediatr Cardiol Yue A, Cui M, Yang Z, Shi Y, Guo C, Song Q (2023) Formula feeding: evidence for health, nutrition and early childhood development during the critical first 1000 days from rural China. J Asian Econ 85:101580 Heaton J, Heller D (2022) Single ventricle. PubMed. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557789/ Weerakkody Y (2024) Transposition of the great arteries. Radiopaedia. Available from: https://radiopaedia.org/articles/transposition-of-the-great-arteries Boston Children’s Hospital. Double outlet right ventricle (DORV). Boston Children’s Hospital. Available from: https://www.childrenshospital.org/conditions/dorv American Heart Association (2019) Atrial septal defect (ASD). Available from: https://www.heart.org/en/health-topics/congenital-heart-defects/about-congenital-heart-defects/atrial-septal-defect-asd Donofrio MT, Massaro AN (2010) Impact of congenital heart disease on brain development and neurodevelopmental outcome. Int J Pediatr 2010:1–13 Sood E, Newburger JW, Anixt JS, Cassidy AR, Jackson JL, Jonas RA, et al. (2024) Neurodevelopmental outcomes for individuals with congenital heart disease: updates in neuroprotection, risk-stratification, evaluation, and management: a scientific statement from the American Heart Association. Circulation 149(13) Clancy T, Jordan B, de Weerth C, Muscara F (2019) Early emotional, behavioural and social development of infants and young children with congenital heart disease: a systematic review. 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(2013) Association of impaired linear growth and worse neurodevelopmental outcome in infants with single ventricle physiology: a report from the Pediatric Heart Network Infant Single Ventricle Trial. J Pediatr 162(2):250-256.e2 Pettigrew J, Tzannes G, Swift L, Docking K, Osland K, Cheng AT (2022) Surgically acquired vocal cord palsy in infants and children with congenital heart disease: description of feeding outcomes. Dysphagia 37 Almuzaini HI, Ibrahim Almuzaini, Megahed Mohamed Hassan (2024) Parents reported language development and scholastic achievement in children with congenital heart diseases versus typically developed. Egypt J Otolaryngol 40(1) Turner T, Nada El Tobgy, Russell K, Day C, Cheung K, Proven S, et al. (2022) Language abilities in preschool children with critical CHD: a systematic review. Cardiol Young 32(5):683–93 Bonthrone AF, Chew A, Kelly CJ, Almedom L, Simpson J, Victor S, et al. (2021) Cognitive function in toddlers with congenital heart disease: the impact of a stimulating home environment. Infancy 26(1):184–99. Available from: https://pubmed.ncbi.nlm.nih.gov/33210418/ Fourdain S, Caron-Desrochers L, Simard MN, Provost S, Amélie Doussau, Gagnon K, et al. (2020) Impacts of an interdisciplinary developmental follow-up program on neurodevelopment in congenital heart disease: the CINC study. Front Pediatr 8 Thomas S, White V, Ryan N, Byrne L (2021) Effectiveness of play therapy in enhancing psychosocial outcomes in children with chronic illness: a systematic review. J Pediatr Nurs 63 Shields GS, Spahr CM, Slavich GM (2020) Psychosocial interventions and immune system function. JAMA Psychiatry 77(10) Kordopati-Zilou K, Sergentanis T, Pervanidou P, Sofianou-Petraki D, Panoulis K, Vlahos N, et al. (2022) Dextro-transposition of great arteries and neurodevelopmental outcomes: a review of the literature. Children 9(4):502 Holst LM, Kronborg JB, Jepsen JRM, Christensen JØ, Vejlstrup NG, Juul K, et al. (2020) Attention-deficit/hyperactivity disorder symptoms in children with surgically corrected ventricular septal defect, transposition of the great arteries, and tetralogy of Fallot. Cardiol Young 30(2):180–7 Kamal AF, Zahraa A, Fakher W, Soltan A, Abdelraouf MM (2024) Cognitive assessment in children with congenital heart diseases after cardiac surgeries. Pediatr Sci J 4(2):65–71 Lau-Jensen SH, Asschenfeldt B, Evald L, Hjortdal VE (2021) Hyperactivity and inattention in young patients born with an atrial septal or ventricular septal defect. Front Pediatr 9 Calderon J, Wypij D, Rofeberg V, Stopp C, Roseman A, Albers D, et al. (2020) Randomized controlled trial of working memory intervention in congenital heart disease. J Pediatr 227:191-198.e3 Williams HM, Hunter K, Clapham K, Ryder C, Kimble R, Griffin B (2020) Efficacy and cultural appropriateness of psychosocial interventions for pediatric burn patients and caregivers: a systematic review. BMC Public Health 20(1) Tesson S, Butow PN, Marshall K, Fonagy P, Kasparian NA (2021) Parent-child bonding and attachment during pregnancy and early childhood following congenital heart disease diagnosis. Health Psychol Rev 16(3):378–411 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6653638","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469364837,"identity":"b8171e96-f6a2-4554-9626-9929cd7029e1","order_by":0,"name":"Vardah Noor Ahmed Bharuchi¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYJACCcYGhgQDEIuxQUKOgQfEYiNBizHJWhgSGwhpMTh+9uGNnzsY8szZzz6T+LnDIr2/54wBw4eyw7i1nEk3tuw9w1Bs2ZNuJtl7RiJ3xtkeA8YZ53BrkWxIY5PgbWNI3HAgjU2asU0it+E8jwEzbxseLf3P2CT/grScfwbWki4P0vIXjxZ+CaDhYFtuQGxJMAA6jJkRr5ZnzNaybRLFBjeeMVv2tkkYbjxzrOBgz7l0nFrY+NMYb75ts8kzOJ/GeONnW5283JnkjQ9+lFnj1AIFEqjcA4TUj4JRMApGwSjADwCas1Kob9Hu7QAAAABJRU5ErkJggg==","orcid":"","institution":"National Stadium Road, Aga Khan University","correspondingAuthor":true,"prefix":"","firstName":"Vardah","middleName":"Noor Ahmed","lastName":"Bharuchi¹","suffix":""},{"id":469364840,"identity":"f4d81e37-46a4-4ef2-b50d-362bff51cd81","order_by":1,"name":"Muneera Abdul Rasheed","email":"","orcid":"","institution":"University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Muneera","middleName":"Abdul","lastName":"Rasheed","suffix":""}],"badges":[],"createdAt":"2025-05-13 09:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6653638/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6653638/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89325379,"identity":"94e012b3-1f03-4fca-9f37-cfc164682693","added_by":"auto","created_at":"2025-08-18 20:16:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1001108,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6653638/v1/9b72b27f-421f-45bb-9a93-048a1115f24d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Effects of Psychosocial Interventions on Mental Status in Pediatric Congenital Heart Defects in a Tertiary Care Hospital in Pakistan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCongenital heart defects (CHDs) are known as structural malformations of the heart that are present at birth. The most common are the septal defects which constitute around 40% of CHD. Septal defects include atrioventricular and ventricular septal defects (VSD). The prevalence of CHD in Pakistan is 3.4 in 1000 and it is estimated that around 60,000 babies are born with CHD annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Approximately 80 patients born with CHD require at least one surgical intervention for complete or palliative cardiac repair [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The median age for CHD surgery is 1.2 to 1.9 years which is the critical age for development [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCHD can be classified according to the severity with most severe being single ventricle defect and the least severe being the arterial septal defect which includes partial anomalous pulmonary venous return (PAPVR). The details of the classification of CHDs are given in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClassification of CHDs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHD Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle Ventricle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis defect covers various cardiac structural abnormalities in which one structure is severely underdeveloped or no formation of ventricular septal wall. Due to anomalous structure, there is a mixing of oxygenated and deoxygenated blood. This occurrence is due to genetic factors, however environmental factors may also cause malformations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransposition of Great Arteries (TGA/VSD and DORV/TGA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransposition of the great arteries (TGA), also known as transposition of the great vessels (TGV), is a common congenital heart defect that causes newborns to have a blue tint to their skin (cyanosis) within the first 24 hours of life. This condition occurs because the main arteries of the heart are switched: the aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. As a result, oxygen-rich blood is not circulated properly throughout the body. There are two main types of TGA based on the position of the aortic and pulmonary valves: L-loop TGA, where the heart has partially corrected itself, and D-loop TGA, which is more common and typically requires immediate medical intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther 2-Ventricle Infant Surgery (TOF, VSD, DORV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDouble outlet right ventricle (DORV) is a rare congenital heart defect that a baby is born with. In this deformity the pulmonary artery and the aorta are connected to the right ventricle. In a normal heart, the pulmonary artery is connected to the right ventricle and the aorta is connected to the left ventricle. This deformity causes problem because the right ventricle carries oxygen-poor blood which is then circulated in the body [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe other heart condition, which is the ventricular septal defect (VSD) occurs with this deformity. VSD is the hole in the tissue wall (septum) which separates right from left ventricles. In VSD, oxygen rich blood is passed from left ventricle to aorta and pulmonary artery. Even though there is added oxygen, the body still does not get enough oxygen, which makes the heart work harder [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial Septal Defects (ASD/PAPVR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe arterial septal defect (ASD) is the whole or a defect in the wall (septum) which separates the top two chambers of the heart which is atria. Because of this opening, the oxygen-rich blood leaks into the oxygen-poor blood chambers. If the ASD is large, the heart and lung work harder and the lung arteries become damaged [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe defects within the heart can be caused by issues in organ, environment and psychological issues of parents. The defects within the heart may affect cerebral development hence for pre-operative care, maximization of cerebral oxygen delivery and utilization is optimized [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Individuals with CHD can have impairment in motor, cognitive skills and language due to these reasons. They also have difficulty with state regulation and during feeding and sleep. Motor skill development is detected earlier among CHD children. This is caused by altered fetal brain development, white matter injury, hospitalizations and postoperative restrictions. Children who undergo surgeries are also at a greater risk for difficulties in adaptive functioning [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatient specific, pre-operative factors and post-operative factors play a role in neurodevelopmental issues in these children. Some surgical and peri-operative factors that can cause neurodevelopmental issues in these children include seizures in infancy, cardiopulmonary resuscitation, mechanical support, heart transplantation and prolonged post-operative hospitalization in infancy. Post-operative hospitalization is a risk factor because of medical complications as well environmental issues such as simulation from bright lights, pain and noise. There is lack of positive stimulation along with maternal separation and oral feeding disruptions during hopsitalization. Other issues that can affect the development of these children include the symptoms of trauma in parents. Other psychological issues that can affect the growth of these children include parental depression, anxiety and severe psychological distress [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Children who undergo surgeries earlier in life with admission in intensive care, painful medical procedures, lengthy hospitalizations and separation from attachment figures can have typically mild development effects, however if these go undetected it can become complex [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, with the improvements of survival rates among newborn, the focus have now changed to neurodevelopmental outcomes for these children across their life span. Preventive measures have been utilized for adverse neurodevelopmental outcomes. One of the interventions is developmental care. Developmental care includes external stimuli control such as auditory, visual, tactile and vestibular stimulation as well as understanding the infant behavioural cues. Other interventions that can help infants include increased participation of parents for the care of their children which can reduce parental anxiety and improve infant neurodevelopment. Habilitative services such as physical, occupation and speech-language therapies can help when timely interventions are given [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEven though benefits of offering interventions before and after hopsitalization have been observed, there is a research gap in understanding the immediate and long-term benefits of providing interventions during hospitalization to CHD patients. Studies in the last decade have shown that early interventions, such as developmental care and increased parental involvement, can positively influence neurodevelopmental outcomes in children with chronic health conditions. Studies by Godino-Ianez et al. (2020) indicate that targeted interventions during hospitalization can mitigate some of the adverse effects associated with prolonged medical treatment and hospitalization. Such adverse effects include negative emotions and behavior and other side-effects [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, research specifically targeting children with CHDs is limited.\u003c/p\u003e \u003cp\u003eThe present study builds on these findings by focusing on a broader range of developmental domains and examining immediate effect. The psychosocial interventions can impact motor skills, speech, communication, mood and affect, cognition, play and interpersonal relationships. These components can be used to understand the mental status of infants and toddlers with CHD. Mental status examination is comprised of functional and cognitive status. Cognitive status includes attention, memory, information processing and functional status includes dependency, physical weakness (such as motor movement) and adaptive functioning [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The present study aims to see whether psychosocial interventions related to motor skills, cognitive skills, emotional and social and language skills during hospitalization will lead to significant improvements in the Mental Status Examination Scale (MSE-S) scores across various domains for pediatric patients with CHD and if it varies by types of CHD.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eStudy Setting and Design\u003c/p\u003e \u003cp\u003eThis study employed an implementation focused research design in a play stimulation intervention conducted in the pediatric ward of a private hospital in Karachi, Pakistan, using purposive sampling from November 2017 to December 2019. This study was part of a bigger study, and details can be found in Rasheed et al. (2021) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The cardiology pediatric ward comprises of one unit with a total of 6 beds. There were 4 beds in the cardiac intensive care unit (CICU) and 6 beds in special care unit. The hospital serves patients from across Pakistan as well as neighboring countries, including Afghanistan, Iran, and Iraq, and caters to individuals from various socio-economic backgrounds. Ethical approval for the study was obtained from the institute\u0026rsquo;s Ethical Research Committee.\u003c/p\u003e \u003cp\u003eImplementation Strategy for the Intervention\u003c/p\u003e \u003cp\u003eIn the initial phase of the study, a theory of change model was developed with the aim of reducing stress for children and their families during hospitalization [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This model identified both internal and external resources and informed the creation of a comprehensive intervention package. This package included an intervention manual designed for children aged one month to six years, featuring activities targeting cognitive, socio-emotional, language, and motor skills (both fine and gross). Additionally, the package comprised behavioral observation forms for both parents and children, as well as a mental status examination form for children. Parental feedback was collected during the final session. Training manuals for nurses and psychology students were also developed, with student performance evaluated using a supervision observation checklist that assessed skills in active listening, core therapeutic conditions, and the application of interventions. A summary of the intervention package is provided in a separate manuscript [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The trainees (psychology students) provided therapy on bedside and aided the caregivers in offering stimulation to their children. Each session would last between the 20 to 40 minutes and students would observe the mental status of children before and after the intervention.\u003c/p\u003e \u003cp\u003eData Collection Measure\u003c/p\u003e \u003cp\u003eMental Status Examination Scale (MSE-S)\u003c/p\u003e \u003cp\u003eThe Mental Status Examination Scale (MSE-S) includes demographic information and evaluates several domains, including motor skills, communication, mood, and attention, both before and after the session. The scale features a variety of question formats: multiple-choice questions for aspects such as session transitions and play themes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], dichotomous questions for orientation to person, place, and time, and multiple-response questions for mood and session transitions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The total score ranges up to 60. The higher the score the better the mental status of the child would be. Domains assessed by the scale include general appearance, motor skills, speech, communication, mood and affect, orientation, thought content, insight and judgment, and interactions with caregivers and therapists. The scale utilizes a combination of rating and branching questions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. For a comprehensive description of the scale, refer to Bharuchi \u0026amp; Rasheed, 2021 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData Collection Procedures, Management, and Analysis\u003c/p\u003e \u003cp\u003eThis study focused on children who received therapy, with interventions constrained by limited resources, meaning not all children in the ward could be included. Therapy was provided based on paediatric cardiologists\u0026rsquo; recommendations or identified by trainees at the bedside. Consent was obtained from caregivers, nurses, and residents. Selection criteria included the child's age, sleep status, and any upcoming procedures, leading to purposive sampling. Sample size calculations were not conducted as this was a quality improvement initiative [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData were collected by trainees before and after the intervention, with sessions conducted by caregivers when possible. In cases where caregivers were unavailable due to consultations or breaks, trainees performed the sessions with prior permission from bedside nurses or residents. Observations included the child\u0026rsquo;s movements, interactions with caregivers, and engagement in play. Each intervention session lasted between 20 to 40 minutes, depending on the child\u0026rsquo;s age, with shorter sessions for younger children. Caregivers were instructed on the activities and encouraged to participate. Children were assessed using the Mental Status Examination Scale (MSE-S) based on their behavior and responses during the intervention. Data from the MSE-S were collected via Google Forms and subsequently compiled in Microsoft Excel. The data were cleaned, cross-checked with discharge summaries from the hospital's online portal, and numerically coded by the first author. The classification of CHD into different types and severity was further done via consulting an experienced researcher in neurodevelopmental outcomes of children with CHD. The CHD types were identified as single ventricle defect, transposition of great arteries, other 2-ventricle infant surgery, arterial septal defects, CHD with genetic condition and other cardiac conditions.\u003c/p\u003e \u003cp\u003eCHD was classified according to the severity with most severe being single ventricle defect and the least severe being the arterial septal defect which includes partial anomalous pulmonary venous return (PAPVR). The details of the classification of CHDs are given in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eDescriptive statistics summarized the quantitative data. Frequencies and mean were analyzed using IBM SPSS for MSE-S subscale scores. Paired samples t-tests examined changes in MSE-S scores before and after the intervention across CHD types.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the descriptive analysis of CHD disease type with gender, age group, number of sessions and length of stay. Most of the children had Other 2-Ventricle Infant Surgery (TOF, VSD, DORV). The details of the disease type are given in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Children who had other procedures were children undergoing procedures like right heart catheterization. Participants were distributed across various CHD classifications, with Other 2-Ventricle being the most common (41.42%), followed by TGA (20.91%) and Single Ventricle (7.69%). Males were predominant in most groups, especially in Single Ventricle (69.23%). Most participants were aged 4\u0026ndash;6 years, though newborns were more common in ASDs (41.67%) and Cardiac Conditions (50.00%). Most attended one session, with fewer attending multiple sessions. The average hospital stay was longest for TGA (22.47 days) and shortest for Other Procedures (3.00 days).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c9\" namest=\"c3\"\u003e \u003cp\u003eCHD Classification\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSingle Ventricle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTGA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOther 2-Ventricle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eASDs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOther Procedures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCardiac Conditions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWith Genetic Conditions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (7.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (20.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70 (41.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (7.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14 (8.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9 (5.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender (N(%))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (69.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (54.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (45.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9 (64.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6 (66.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (30.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (45.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (54.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5 (35.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3 (33.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Group (N (%))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNewborns \u0026ndash; 6 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (18.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (41.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3 (33.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e7\u0026ndash;12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (30.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (11.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (27.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 (11.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e13\u0026ndash;24 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (8.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (17.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (21.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2\u0026ndash;3 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (14.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (15.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4 (44.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4\u0026ndash;6 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (61.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (48.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (21.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 (21.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 (11.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSession (N (%))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (61.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (54.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38 (54.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (83.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7 (77.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (15.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (14.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (32.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5 (35.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2 (22.22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (15.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (11.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 (7.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5 and more\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (17.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (4.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of Stay (M (SD))\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.85 (9.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.47 (23.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.24 (9.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.67 (2.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.71 (2.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14.33 (13.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows a series of paired samples t-tests were conducted (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) to compare the Mental Status Examination Scale (MSE-S) scores before and after the intervention across different categories of congenital heart disease (CHD).\u003c/p\u003e \u003cp\u003eFor patients with single ventricle conditions, there was a significant decrease in MSE-S scores from before the intervention (M\u0026thinsp;=\u0026thinsp;37.46, SD\u0026thinsp;=\u0026thinsp;9.32) to after the intervention (M\u0026thinsp;=\u0026thinsp;42.92, SD\u0026thinsp;=\u0026thinsp;12.6), t(12)\u0026thinsp;=\u0026thinsp;2.72, p\u0026thinsp;=\u0026thinsp;.018, 95% CI [9.83, 1.09], with a mean difference of 5.46 (SD\u0026thinsp;=\u0026thinsp;7.23).\u003c/p\u003e \u003cp\u003eFor patients with transposition of the great arteries (TGA), there was a significant decrease in MSE-S scores from before (M\u0026thinsp;=\u0026thinsp;35.77, SD\u0026thinsp;=\u0026thinsp;7.75) to after the intervention (M\u0026thinsp;=\u0026thinsp;40.46, SD\u0026thinsp;=\u0026thinsp;8.61), t(34)\u0026thinsp;=\u0026thinsp;5.9, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [6.3, 3.07], with a mean difference of 4.69 (SD\u0026thinsp;=\u0026thinsp;4.7).\u003c/p\u003e \u003cp\u003eFor patients who underwent other 2-ventricle infant surgeries, there was a significant decrease in MSE-S scores from before (M\u0026thinsp;=\u0026thinsp;32.43, SD\u0026thinsp;=\u0026thinsp;10.2) to after the intervention (M\u0026thinsp;=\u0026thinsp;38.7, SD\u0026thinsp;=\u0026thinsp;9.21), t(69)\u0026thinsp;=\u0026thinsp;9.96, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, 95% CI [7.53, 5.02], with a mean difference of 6.27 (SD\u0026thinsp;=\u0026thinsp;5.27).\u003c/p\u003e \u003cp\u003eFor patients with atrial septal defects (ASDs), the decrease in MSE-S scores from before (M\u0026thinsp;=\u0026thinsp;29.75, SD\u0026thinsp;=\u0026thinsp;15.04) to after the intervention (M\u0026thinsp;=\u0026thinsp;33.83, SD\u0026thinsp;=\u0026thinsp;13.48) was not statistically significant, t(11)\u0026thinsp;=\u0026thinsp;2.06, p\u0026thinsp;=\u0026thinsp;.064, 95% CI [8.46, 0.29], with a mean difference of 4.08 (SD\u0026thinsp;=\u0026thinsp;6.88).\u003c/p\u003e \u003cp\u003eFor patients who underwent other procedures, there was a significant decrease in MSE-S scores from before (M\u0026thinsp;=\u0026thinsp;27.33, SD\u0026thinsp;=\u0026thinsp;10.6) to after the intervention (M\u0026thinsp;=\u0026thinsp;33, SD\u0026thinsp;=\u0026thinsp;12.12), t(2)\u0026thinsp;=\u0026thinsp;6.43, p\u0026thinsp;=\u0026thinsp;.023, 95% CI [9.46, 1.87], with a mean difference of 5.67 (SD\u0026thinsp;=\u0026thinsp;1.53).\u003c/p\u003e \u003cp\u003eFor patients with other cardiac conditions, there was a significant decrease in MSE-S scores from before (M\u0026thinsp;=\u0026thinsp;30.93, SD\u0026thinsp;=\u0026thinsp;11.23) to after the intervention (M\u0026thinsp;=\u0026thinsp;36.79, SD\u0026thinsp;=\u0026thinsp;11.4), t(13)\u0026thinsp;=\u0026thinsp;3.82, p\u0026thinsp;=\u0026thinsp;.002, 95% CI [9.17, 2.55], with a mean difference of 5.86 (SD\u0026thinsp;=\u0026thinsp;5.74).\u003c/p\u003e \u003cp\u003eFor patients with genetic conditions, there was a significant decrease in MSE-S scores from before (M\u0026thinsp;=\u0026thinsp;29.89, SD\u0026thinsp;=\u0026thinsp;12.14) to after the intervention (M\u0026thinsp;=\u0026thinsp;36.78, SD\u0026thinsp;=\u0026thinsp;12.85), t(8)\u0026thinsp;=\u0026thinsp;3.62, p\u0026thinsp;=\u0026thinsp;.007, 95% CI [11.28, 2.5], with a mean difference of 6.89 (SD\u0026thinsp;=\u0026thinsp;5.71).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePaired Samples T Test of Categories of CHD and score on MSE-S\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSig\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSingle Ventricle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTGA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther 2-ventricle infant surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASDs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther procedures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCardiac conditions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWith Genetic Conditions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the mean scores for the MSE-S subscales before and after the intervention across different classifications. Overall, improvements were observed in several domains following the intervention.\u003c/p\u003e \u003cp\u003eSingle Ventricle: There were notable improvements in motor skills (mean increased from 5.44 to 6.00) and play observation (mean increased from 5.46 to 6.85). Communication, mood, and affect showed minor changes, with stable scores in general appearance.\u003c/p\u003e \u003cp\u003eTGA: Motor skills improved moderately (mean increased from 4.26 to 4.83), while slight increases were seen in communication and mood/affect. Scores for play observation remained consistent.\u003c/p\u003e \u003cp\u003eOther 2-ventricle infant surgeries: Improvements were observed in motor skills (mean increased from 4.60 to 4.93) and play observation (mean increased from 4.64 to 6.57). Communication and mood scores increased modestly.\u003c/p\u003e \u003cp\u003eASDs: Motor skills and play observation scores improved (mean increased from 4.57 to 4.71 and from 5.45 to 6.64, respectively). Mood and communication domains showed minor increases.\u003c/p\u003e \u003cp\u003eOther procedures: Scores for play observation increased (mean increased from 4.33 to 7.00), while other domains, such as general appearance and motor skills, remained relatively unchanged.\u003c/p\u003e \u003cp\u003eCardiac Conditions: Improvements were noted in motor skills (mean increased from 4.00 to 5.33) and play observation (mean increased from 5.50 to 6.57). Communication and mood showed slight improvements as well.\u003c/p\u003e \u003cp\u003eWith Genetic Conditions: Moderate improvements were observed in play observation (mean increased from 5.22 to 6.22) and cognition (mean increased from 8.00 to 10.67).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean Scores before and after the intervention of MSE-S subscales\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"14\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral Appearance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMotor skills\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eSpeech\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eMood \u0026amp; affect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCognition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003ePlay Observation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e \u003cp\u003eInterpersonal Relationship\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eAfter Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSingle Ventricle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.69 (1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.31 (1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.44 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.3 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.3 (0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.46 (2.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.85 (1.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e11.08 (3.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10.23 (1.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e7.46 (2.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e7.38 (2.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTGA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.57 (1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.57 (1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.26 (1.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.83 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.6 (1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.85 (1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.6 (1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.85 (1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e11.49 (2.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9.86 (2.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e7.31 (2.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e8.23 (2.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther 2-ventricle infant surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.53 (1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.56 (1.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.6 (1.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.93 (1.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.27 (1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.53 (1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.64 (1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.57 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9.2 (3.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9.93 (2.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e7.03 (2.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e7.3 (2.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASDs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.92 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.42 (1.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.57 (1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.71 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (1.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.63 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.45 (2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.64 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8.82 (4.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9.75 (2.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e6.2 (3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e7.09 (3.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther procedures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.33 (0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.33 (1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.17 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.13 (1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.33 (3.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7 (1.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.67 (2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e11.67 (0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e9.5 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e7 (4.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCardiac conditions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.29 (1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.14 (2.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.33 (1.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.78 (1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.67 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.5 (2.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.57 (2.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10.93 (1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10.93 (1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e7.57 (3.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e8.14 (2.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWith Genetic Conditions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.67 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.25 (1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.29 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.25 (1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.63 (1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.22 (2.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.22 (2.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8 (4.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10.67 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e6.33 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e8.22 (2.39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.5 (1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.67 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.71 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.2 (1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.9 (1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10.7(3.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9.6 (2.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e8.25 (2.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e9.4 (1.58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOverall significant difference in mean on MSE-S was observed before and after intervention for all classifications of CHD except for ASDs. This proves the hypothesis that interventions had a significant impact on the mental status of infants and toddlers with CHD. It has been found out that spiritually sensitive interventions can decrease the depressive symptoms of hospitalized children with CHD [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Nursing interventions (education and empathic interviewing, therapeutic play interventions and motor exercise) in perioperative stage have been found to reduce the complication and pain in the post-operative stage which led to reduced length of stay [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA significant difference before and after the intervention was not observed in children with ASD. One reason could be because these children may not have been psychologically affected as much as the children with other conditions as ASD is not as severe as the other conditions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This can be further supported by a study that was conducted that showed that the scores on the health-related quality of life of ASD children was similar to control group children without heart defects [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Other factors that can also impact the mental status could be parental stress, parental involvement, time of intervention and duration of hospital stay [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen subscales of MSE-S were investigated, different scores were observed for different conditions. For motor skills, CHD children with genetic conditions scored the lowest in the present study. Around 30% of the children with CHD have underlying genetic anomaly that can lead to worse neurodevelopmental outcomes including motor delays as compared to children with CHD but without genetic conditions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The time of surgery such as whether the child received surgery at an earlier age as compared to later age also impacts the motor skills. Other factors for poor motor skills include oxygen saturation level below 85% and immobilization after surgery [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The age of the child can also be a cause for poor motor skills as studies have found out that the prevalence of abnormal motor development is highest between 0 to 12 months and the prevalence seems to decrease in the months of 12 to 24 months and it decreases further when the child is 24 to 36 months old [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This can explain the difference in the motor skills score in different categories of CHD.\u003c/p\u003e \u003cp\u003eOne subscale of MSE-S was speech which was measured by looking at the child\u0026rsquo;s frequency of saying words and babbling as well as the volume [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Children from all categories of CHD scored above 4 out of the total score of 6 before and after intervention. Children post-surgery are at risk for developing vocal cord palsy and children with genetic conditions are more at risk for developing this condition [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Motor delays also play an important role in speech production [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Children with CHD have delays in babbling, first-word production, two-word sentences, etc. However, to improve the quality-of-life early family counselling and language therapy are recommended [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. With subscale of speech, communication was also measured. The score on communication domain was measured via assessing receptive language and expressive language such as instruction following and age-appropriate speech, was almost the same before and after the intervention. The total score was out of 4 and in most categories of CHD, infants and toddlers scored above 2. Children with CHD have lower receptive and expressive language skills as compared to children without CHD [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, a study on 22 months old toddlers found out that stimulating home environment of CHD children can improve cognitive and language outcomes [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Children who took part in the follow-up neurodevelopment and intervention programs reported to have better language and communication outcomes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Hence, if interventions are introduced during hospitalization, it can benefit CHD children in speech and language development.\u003c/p\u003e \u003cp\u003eMost of the children scored above 4 out of the total score of 8 on the subscale of mood and affect before the intervention and above 6 after intervention. Children with TGA had an average score of 2.60 and 2.85 after intervention. Psychosocial interventions play a significant role in the mood and affect of chronically ill children [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Studies have also found out that psychosocial stimulation improves the immune system function [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The low score on mood and affect of children with TGA can be explained by chronic post-operative complications and perinatal impaired cerebral oxygen delivery [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Survivors of TGA are at increased risk for developing ADHD, anxiety and depression [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCognition is another subscale from MSE-S. The total score was out of 15 and the subscale measures attention, orientation, intelligence and thought content. The lowest score was obtained by CHD children with genetic conditions and ASDs followed by other 2-ventricle infant surgery. Children from other categories scored above 10. In a study that was conducted on children it was found out that scores of cognitions were dependent on when the child had surgery [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In another study it was found out that individuals with simple congenital heart defect have a higher symptom of ADHD [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Interventions in follow-up appointments related to attention and cognition can improve these functions [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePlay observation is another component of MSE-S. It measures whether the theme of play, type of play and transition out of the session is positive or negative. The total score is out of 15 and average score of children from all categories was above 9 which shows that the play was mostly positive. Studies on chronically ill children have shown that play has positive impact and improves symptoms of depression and self-concept [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Non-pharmacological interventions such as play and other psychosocial interventions can help in reducing the symptoms of pain as well as caregivers\u0026rsquo; anxiety, distress and trauma symptoms [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Play and psychosocial interventions can be used with CHD children to enhance positive mood as well as self-concept.\u003c/p\u003e \u003cp\u003e The MSE-S measured the interpersonal relationship with caregivers and trainees before and after the sessions. Children from most categories scored above 7 before and after intervention except for children with ASD and CHD with genetic condition. Children with genetic condition may have scored low due to challenges with genetic disorders as these children are more susceptible to neurodevelopmental issues. Children with CHD have difficulties in social and behavioural development which can lead to externalizing and internalizing behaviour issues [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Maternal-fetal bonding can enhance interpersonal relationship as well as the sensitivity and responsiveness of parents while interacting with their child after the diagnosis. Maternal anxiety is related to interpersonal relationship. Parental involvement with the child can impact emotional health of the child. It is has been found out that some parents after receiving the diagnosis are not as responsive and may withdraw in adequate caregiving [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Caregiver interaction at the time of diagnosis and hospitalization for CHD children can improve the psychological outcomes which includes interpersonal relationships.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the sample size was relatively small, and the study was conducted in a single pediatric ward of a private hospital in Karachi, Pakistan. This limits the generalizability of the findings to other settings and populations. Second, the study utilized purposive sampling, which may introduce selection bias and affect the representativeness of the sample. Third, due to the constraints of limited resources, not all children in the ward could be included in the intervention, potentially influencing the outcomes. Additionally, the study did not conduct sample size calculations as it was part of a quality improvement initiative, which may impact the statistical power of the findings. Furthermore, the intervention sessions varied in length and caregiver participation, which could have influenced the consistency of the intervention's effects. The reliance on caregiver and trainee observations for data collection may also introduce observer bias. Lastly, the study did not account for potential confounding variables such as the severity of the cardiac condition, the child\u0026rsquo;s pre-existing developmental status, and the duration of hospital stay, which could affect the outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study indicate that psychosocial interventions during hospitalization are associated with improvements in Mental Status Examination Scale (MSE-S) scores across various domains for pediatric patients with congenital heart defects (CHD). Significant improvements were observed in overall MSE-S scores, as well as in subscales measuring motor skills, speech, communication, mood and affect, cognition, play observation, and interpersonal relationships. These results highlight the potential benefits of incorporating developmental care and increased parental involvement during hospitalization to enhance neurodevelopmental outcomes in children with CHD. However, the limitations of this study suggest the need for further research with larger, more diverse samples and controlled study designs to confirm these findings and understand the long-term impacts of such interventions. Future studies can also consider the role of additional factors such as the severity of the condition, pre-existing developmental status, and hospital stay duration in influencing outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eHuman Ethics and Consent to Participate\u003c/h2\u003e \u003cp\u003eThis study was part of a broader transformative initiative undertaken by the Children\u0026rsquo;s Hospital of The Aga Khan University. At the time of admission, caregivers were informed about the initiative, and general consent was obtained. Specific consent for this service was waived, as it was included in the standard consent procedure prior to hospitalization. Verbal consent was sought from caregivers before the interventions from this study were given.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics Approval:\u003c/h2\u003e \u003cp\u003e This study was part of a larger quality improvement initiative aimed at enhancing patient experience in the Paediatric Service Line, approved by the Ethics Review Committee of The Aga Khan University. For this study, Ethical approval was granted by Dr. Jamsheer Talati, Chair of the Ethics Review Committee. The ERC approval number is 4778-Ped-ERC-17. All procedures followed the ethical standards outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical trial number\u003c/strong\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding :\u003c/h2\u003e \u003cp\u003eThe project was funded by Aga Khan University\u0026rsquo;s Children\u0026rsquo;s Hospital.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eV.B.: data curation (lead), formal analysis (lead), investigation (supporting), methodology (equal), project administration (equal), writing- original draft (lead). M.R.: conceptualization (lead), investigation (lead), methodology (equal), project administration (equal), resources (lead), supervision (lead), writing -review and editing (lead).\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe extend our heartfelt gratitude to Dr. Babar Hasan for his unwavering support throughout this study. We also sincerely thank Dr. Adam Cassidy for his invaluable guidance in writing this manuscript. Additionally, we acknowledge the contributions of the students from the Institute of Professional Psychology, Bahria University, whose efforts were instrumental in this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData can be available upon request to the principal investigator (PI) of the study. The PI can be contacted via:[email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSyed Irtiza Ali, Obaid Yusuf Khan, Naveed N, Ahmad H, Patel N, Arif A (2024) Congenital septal defects in Karachi, Pakistan: an update of mutational screening by high-resolution melting (HRM) analysis of MTHFR C677T. Hum Genomics 18(1)\u003c/li\u003e\n\u003cli\u003eZahid I, Tariq M, Hashmi S, Amanullah M, Shahabuddin S (2021) The Glenn procedure: Clinical outcomes in patients with congenital heart disease in Pakistan. Ann Card Anaesth 24(1):30\u003c/li\u003e\n\u003cli\u003eNakayama Y, Horimoto Y, Suzuki K, Takiguchi M, Ishihara K, Umehara N, et al. (2024) Clinical course of residual ventricular septal defects after congenital heart disease repair. Pediatr Cardiol\u003c/li\u003e\n\u003cli\u003eYue A, Cui M, Yang Z, Shi Y, Guo C, Song Q (2023) Formula feeding: evidence for health, nutrition and early childhood development during the critical first 1000 days from rural China. J Asian Econ 85:101580\u003c/li\u003e\n\u003cli\u003eHeaton J, Heller D (2022) Single ventricle. PubMed. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557789/\u003c/li\u003e\n\u003cli\u003eWeerakkody Y (2024) Transposition of the great arteries. Radiopaedia. Available from: https://radiopaedia.org/articles/transposition-of-the-great-arteries\u003c/li\u003e\n\u003cli\u003eBoston Children\u0026rsquo;s Hospital. Double outlet right ventricle (DORV). Boston Children\u0026rsquo;s Hospital. Available from: https://www.childrenshospital.org/conditions/dorv\u003c/li\u003e\n\u003cli\u003eAmerican Heart Association (2019) Atrial septal defect (ASD). Available from: https://www.heart.org/en/health-topics/congenital-heart-defects/about-congenital-heart-defects/atrial-septal-defect-asd\u003c/li\u003e\n\u003cli\u003eDonofrio MT, Massaro AN (2010) Impact of congenital heart disease on brain development and neurodevelopmental outcome. Int J Pediatr 2010:1\u0026ndash;13\u003c/li\u003e\n\u003cli\u003eSood E, Newburger JW, Anixt JS, Cassidy AR, Jackson JL, Jonas RA, et al. (2024) Neurodevelopmental outcomes for individuals with congenital heart disease: updates in neuroprotection, risk-stratification, evaluation, and management: a scientific statement from the American Heart Association. Circulation 149(13)\u003c/li\u003e\n\u003cli\u003eClancy T, Jordan B, de Weerth C, Muscara F (2019) Early emotional, behavioural and social development of infants and young children with congenital heart disease: a systematic review. J Clin Psychol Med Settings 27(4):686\u0026ndash;703\u003c/li\u003e\n\u003cli\u003eGodino-I\u0026aacute;\u0026ntilde;ez MJ, Martos-Cabrera MB, Suleiman-Martos N, G\u0026oacute;mez-Urquiza JL, Vargas-Rom\u0026aacute;n K, Membrive-Jim\u0026eacute;nez MJ, et al. (2020) Play therapy as an intervention in hospitalized children: a systematic review. Healthcare 8(3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551498/\u003c/li\u003e\n\u003cli\u003eBharuchi V, Rasheed MA (2022) Development and feasibility testing of the mental status examination scale to assess functional status of young, hospitalized children in Pakistan. SSM Ment Health 2:100126\u003c/li\u003e\n\u003cli\u003eRasheed MA, Bharuchi V, Mughis W, Hussain A (2021) Development and feasibility testing of a play-based psychosocial intervention for reduced patient stress in a pediatric care setting: experiences from Pakistan. Pilot Feasibility Stud 7(1)\u003c/li\u003e\n\u003cli\u003eSoltan M, Girguis J (2017) How to approach the mental state examination. BMJ 357(1). Available from: https://www.bmj.com/content/357/sbmj.j1821\u003c/li\u003e\n\u003cli\u003eDeCastellarnau A (2017) A classification of response scale characteristics that affect data quality: a literature review. Qual Quant 52(4):1523\u0026ndash;59. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993837/\u003c/li\u003e\n\u003cli\u003ePandya SP (2019) Spiritually sensitive intervention to mitigate depressive symptoms among hospitalized children affected with congenital heart diseases: insights for holistic pediatric nursing. J Holist Nurs 38(1):78\u0026ndash;88\u003c/li\u003e\n\u003cli\u003eDing X, Wen J, Yue X, Zhao Y, Qi C, Wang D, et al. (2022) Effect of comprehensive nursing intervention for congenital heart disease in children: a meta-analysis. Medicine 101(41):e31184. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9575750/\u003c/li\u003e\n\u003cli\u003eLiu HC, Chaou CH, Lo CW, Chung HT, Hwang MS (2022) Factors affecting psychological and health-related quality-of-life status in children and adolescents with congenital heart diseases. Children 9(4):578\u003c/li\u003e\n\u003cli\u003eSprong MCA, Broeders W, van der Net J, Breur JMPJ, de Vries LS, Slieker MG, et al. (2021) Motor developmental delay after cardiac surgery in children with a critical congenital heart defect: a systematic literature review and meta-analysis. Pediatr Phys Ther 33(4):186\u0026ndash;97\u003c/li\u003e\n\u003cli\u003eMajnemer A, Limperopoulos C, Shevell MI, Rohlicek C, Rosenblatt B, Tchervenkov C (2009) A new look at outcomes of infants with congenital heart disease. Pediatr Neurol 40(3):197\u0026ndash;204\u003c/li\u003e\n\u003cli\u003eSarajuuri A, Tuula L\u0026ouml;nnqvist, Mildh L, Irmeli Rajantie, Matti Eronen, Mattila I, et al. (2009) Prospective follow-up study of children with univentricular heart: neurodevelopmental outcome at age 12 months. J Thorac Cardiovasc Surg 137(1):139-145.e2\u003c/li\u003e\n\u003cli\u003eRavishankar C, Zak V, Williams IA, Bellinger DC, J. William Gaynor, Ghanayem NS, et al. (2013) Association of impaired linear growth and worse neurodevelopmental outcome in infants with single ventricle physiology: a report from the Pediatric Heart Network Infant Single Ventricle Trial. J Pediatr 162(2):250-256.e2\u003c/li\u003e\n\u003cli\u003ePettigrew J, Tzannes G, Swift L, Docking K, Osland K, Cheng AT (2022) Surgically acquired vocal cord palsy in infants and children with congenital heart disease: description of feeding outcomes. Dysphagia 37\u003c/li\u003e\n\u003cli\u003eAlmuzaini HI, Ibrahim Almuzaini, Megahed Mohamed Hassan (2024) Parents reported language development and scholastic achievement in children with congenital heart diseases versus typically developed. Egypt J Otolaryngol 40(1)\u003c/li\u003e\n\u003cli\u003eTurner T, Nada El Tobgy, Russell K, Day C, Cheung K, Proven S, et al. (2022) Language abilities in preschool children with critical CHD: a systematic review. Cardiol Young 32(5):683\u0026ndash;93\u003c/li\u003e\n\u003cli\u003eBonthrone AF, Chew A, Kelly CJ, Almedom L, Simpson J, Victor S, et al. (2021) Cognitive function in toddlers with congenital heart disease: the impact of a stimulating home environment. Infancy 26(1):184\u0026ndash;99. Available from: https://pubmed.ncbi.nlm.nih.gov/33210418/\u003c/li\u003e\n\u003cli\u003eFourdain S, Caron-Desrochers L, Simard MN, Provost S, Am\u0026eacute;lie Doussau, Gagnon K, et al. (2020) Impacts of an interdisciplinary developmental follow-up program on neurodevelopment in congenital heart disease: the CINC study. Front Pediatr 8\u003c/li\u003e\n\u003cli\u003eThomas S, White V, Ryan N, Byrne L (2021) Effectiveness of play therapy in enhancing psychosocial outcomes in children with chronic illness: a systematic review. J Pediatr Nurs 63\u003c/li\u003e\n\u003cli\u003eShields GS, Spahr CM, Slavich GM (2020) Psychosocial interventions and immune system function. JAMA Psychiatry 77(10)\u003c/li\u003e\n\u003cli\u003eKordopati-Zilou K, Sergentanis T, Pervanidou P, Sofianou-Petraki D, Panoulis K, Vlahos N, et al. (2022) Dextro-transposition of great arteries and neurodevelopmental outcomes: a review of the literature. Children 9(4):502\u003c/li\u003e\n\u003cli\u003eHolst LM, Kronborg JB, Jepsen JRM, Christensen J\u0026Oslash;, Vejlstrup NG, Juul K, et al. (2020) Attention-deficit/hyperactivity disorder symptoms in children with surgically corrected ventricular septal defect, transposition of the great arteries, and tetralogy of Fallot. Cardiol Young 30(2):180\u0026ndash;7\u003c/li\u003e\n\u003cli\u003eKamal AF, Zahraa A, Fakher W, Soltan A, Abdelraouf MM (2024) Cognitive assessment in children with congenital heart diseases after cardiac surgeries. Pediatr Sci J 4(2):65\u0026ndash;71\u003c/li\u003e\n\u003cli\u003eLau-Jensen SH, Asschenfeldt B, Evald L, Hjortdal VE (2021) Hyperactivity and inattention in young patients born with an atrial septal or ventricular septal defect. Front Pediatr 9\u003c/li\u003e\n\u003cli\u003eCalderon J, Wypij D, Rofeberg V, Stopp C, Roseman A, Albers D, et al. (2020) Randomized controlled trial of working memory intervention in congenital heart disease. J Pediatr 227:191-198.e3\u003c/li\u003e\n\u003cli\u003eWilliams HM, Hunter K, Clapham K, Ryder C, Kimble R, Griffin B (2020) Efficacy and cultural appropriateness of psychosocial interventions for pediatric burn patients and caregivers: a systematic review. BMC Public Health 20(1)\u003c/li\u003e\n\u003cli\u003eTesson S, Butow PN, Marshall K, Fonagy P, Kasparian NA (2021) Parent-child bonding and attachment during pregnancy and early childhood following congenital heart disease diagnosis. Health Psychol Rev 16(3):378\u0026ndash;411\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Congenital Heart Disease, psychosocial intervention, mental status, paediatrics","lastPublishedDoi":"10.21203/rs.3.rs-6653638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6653638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCongenital heart defects (CHD) are structural heart malformations present at birth, often requiring early surgical interventions during critical developmental stages. Children with CHD are at risk for neurodevelopmental challenges, exacerbated by hospitalization and parental stress. This study evaluates the impact of psychosocial interventions during hospitalization on the mental status of pediatric CHD patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA quality improvement study was conducted in a tertiary care hospital in Karachi, Pakistan, from 2017 to 2019. The intervention utilized a Mental Status Examination Scale (MSE-S) to measure changes in mental status before and after psychosocial interventions. Purposive sampling included children aged 1 month to 6 years with CHD undergoing hospitalization. Descriptive analysis and paired samples T test were used.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant improvements were observed in MSE-S scores across most CHD classifications. MSE-S scores in Single Ventricle group, increased from 37.46 (SD\u0026thinsp;=\u0026thinsp;9.32) to 42.92 (SD\u0026thinsp;=\u0026thinsp;12.6) (p\u0026thinsp;=\u0026thinsp;0.018), while for Transposition of Great Arteries, scores rose from 35.77 (SD\u0026thinsp;=\u0026thinsp;7.75) to 40.46 (SD\u0026thinsp;=\u0026thinsp;8.61) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The other 2-Ventricle group showed the largest improvement, from 32.43 (SD\u0026thinsp;=\u0026thinsp;10.2) to 38.70 (SD\u0026thinsp;=\u0026thinsp;9.21) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Improvements were consistent in motor skills, speech, mood, and cognition subscales.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePsychosocial interventions during hospitalization significantly improve mental status of CHD children. These findings underscore the importance of developmental care and parental involvement in improving the mental and emotional well-being of pediatric patients. Further research with larger and diverse samples is warranted to generalize findings and explore long-term benefits.\u003c/p\u003e","manuscriptTitle":"Exploring the Effects of Psychosocial Interventions on Mental Status in Pediatric Congenital Heart Defects in a Tertiary Care Hospital in Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 10:54:42","doi":"10.21203/rs.3.rs-6653638/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"296732fc-6179-4a4d-b31e-549e1a076b8f","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T20:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-12 10:54:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6653638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6653638","identity":"rs-6653638","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}