Attention and executive functioning in pediatric congenital heart disease: a construct-based approach

This study characterizes the attention and executive functioning (EF) profile of school-age children with congenital heart disease (CHD) using a construct-based approach. It was hypothesized that difficulties in specific attention/EF constructs would be evident, and degree of difficulty would vary by CHD complexity and neurodevelopmental diagnosis.

Demographic, medical, and neuropsychological data were retrospectively examined from 154 children with CHD aged 6-16 years seen for neuropsychological evaluation between October 2013 and October 2024. Exploratory factor analysis yielded six attention/EF constructs. Constructs were compared to normative means. Frequency of impairment was calculated. CHD complexity and DSM-5 diagnosis on constructs were analyzed with multivariate analysis of variance.

All attention/EF construct scores were significantly lower than normative means. Frequency of impairment varied across constructs; one-third of participants had exceptionally low and below average performances within processing speed, attention, and impulse control constructs. Clinical or subclinical functional inattention and hyperactivity was reported in half of participants, with clinical symptoms reported in one-fourth. Children with simple CHD had worse impulse control and functional inattention and hyperactivity compared to those with complex CHD. Those with only a neurodevelopmental diagnosis performed lower than those with no DSM-5 diagnosis.

Children with CHD had attention/EF deficits across multiple constructs (i.e. skill areas), although frequency and severity of impairment varied by construct. This suggests children with CHD have a neurobehavioral profile that may not fully align with traditional diagnostic categories, which has implications both for diagnosis and intervention. Greater difficulties observed in children with simple CHD emphasize the importance of neurodevelopmental monitoring of all CHD types. Neurodevelopmental diagnosis was associated with lower processing speed, but this skill is not a core diagnostic feature of a neurodevelopmental disorder. Thus, consideration of dimensional diagnostic approaches within a clinical patient population such as CHD is warranted.