Psychosocial Effects of Short Stature Several early psychological studies of children with short stature showed an increased percentage of problems, including

stigmatization and juvenilization social aversion Anxiety , depression

attention problems lower social skills achieved by GHD adults

difficulty in school

academic underachievement, despite average intelligence, but are probably due to specific neurocognitive deficits associated with the particular syndrome

. Treating the child according to height age rather than chronological age may condition him or her to behave in a socially immature manner and to seek out younger children or adults. Alternatively, children with SS may be (or may be seen as) physically weaker than their peers, leading to parental overprotection, in itself a potent predictor of victimization by peers

in the general school population.

. In a recent survey, 56% of physicians felt that height impaired emotional well-being in children below the 3rd centile. Thirty-two percent of these same physicians also believed that quality of life in non-GHD SS could be improved by an increase in height.

It is sometimes assumed that delayed puberty, often associated with SS, will compound any psychological problems. It has even been suggested that the benefits of advancing puberty might outweigh the potential risk of attenuated adult height. The evidence, however, is inconclusive. One follow-up study of constitutional growth delay revealed that many subjects remained unemployed and economically dependent on their parents as young adults, but that the level of educational attainment had not been seriously affected

benefits of therapy for these children with short stature

greater cognitive functioning

increased overall happiness and self-esteem that is gained with increased height

increased productivity and contribution to society as higher functioning adults

treatment of children with short stature ( growth hormone therapy). treatment is both painful, requiring many injections for years, as well as extremely expensive, both for the children's parents as well as for

medical health care for society. treatment expanding over the years to include children with short stature who are not growth hormone deficient it is important to determine all potential benefits beyond the obvious physical effects in order to make efficient cost-benefit Add significant height to children who are growth hormone deficient.

Since the introduction of recombinant growth hormone (GH) therapy in 1985, a vast number of children have undertaken therapy to improve their eventual adult height. While it is well established that GH therapy will have a positive effect on height, the impact on psychological factors is less proven. It has been assumed that children of short stature experience behavioral disorders ,that an increase in height would alleviate these events, resulting in adults that would have greater cognitive functioning than they would have if they were not treated..

If this hypothesis was proven to be valid, the overall financial cost of GH therapy would be lessened, both by the reduced amount of psychological services required by these children as well as the increased productivity and contribution to society as higher functioning adults

many studies were examined in order to validate the hypothesis that GH therapy would have a beneficial effect on the psychological aspects of children.

-First study

-compared 195 children of short stature with a control group and measured the prevalence of behavioral and learning problems.

- The children were further classified as being GHD or idiopathic short stature (ISS) via responsiveness to stimulation testing.

-Overall, a greater number of short stature children had difficulty in school and suffered from behavioral problems than those of controls. No differences were observed specifically between the GHD group and those of ISS.

-There were no statistically significant differences in academic achievement observed between the two groups.

- After three years of GH therapy in both the groups, both showed improvement in an overall psychological functioning as measured by the Total Behavior Problem scale. Those with GHD, however, showed significant improvement in 7 out of the 8 individual factors, as compared to 2 for ISS, with both groups improving in the Anxious/Depressed , Social Problems subscales

2nd study -

compared sixty short stature children using the Visual Analogue Scale for Children (VASC), again separating GHD children from ISS by stimulation testing. The group of children who were GHD had a more negative self-perception of their physical appearance than compared to controls, which was not seen when those with ISS were compared to those of normal stature, perhaps due to the other physical effects of GHD on muscle formation and adipose deposition in tissues. The authors then took the next step of correlating the maximum amount of GH stimulated during testing to the same VASC subscales

The results showed a strong negative correlation between the maximal GH amount of the children and the inhibition subscale, stating that the children that have the least amount of GH were described as being more inhibited by both the children themselves as well as their parents. It has been theorized that since the neuro-endocrine centers that modulate mood and affect are functionally related to GH secretion by the pituitary, that decreased amounts of GH available would have a negative effect on these psychological factors. This theory may explain the lower social skills achieved by GHD adults which have been consistently revealed by other studies

_3rd study

examined children born small for gestational age (SGA) in the Netherlands, treated them with GH, and followed them for two and eight years, obtaining psychological values at baseline as well as each follow-up visit. The children were not divided between GHD and ISS. At baseline, the SGA children showed lower values in performance IQ as compared to population controls. This value improved significantly at two years post-GH therapy and at eight years This effect was also seen in other areas, such as behavioral problems, which decreased from above the norm at baseline to average values. The most dramatic effect was seen in the mean self-perception scale, where the SGA children showed values well below the mean at baseline, was equivalent at two years post-treatment, and actually exceeded the average at eight years post GH therapy.

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Finally, following adolescents who had been treated for GHD after their treatments were terminated due to their achievement of total adult height. These young adults were studied over a two year period to determine if the abrupt cessation of GH had a negative psychological effect. The data was further separated into those with GHD and those classified as GH sufficient, which is equivalent to the ISS category

While those with GHD had a decline in sociability and an increase in anxiety, not seen in the ISS group, there was no measurable decline in overall quality of life in either group of subjects. Therefore, any potential psychological gain made during GH therapy does not appear to deteriorate once therapy had ceased.

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The Wessex Growth study

a prospective cohort study, was unique for having recruited an unselected population of very short, but otherwise healthy children, from the age of 5 years . Children with known organic disease were excluded, the age range lay within a tight band, a wide range of socio-economic classes was represented, and the study incorporated case-matched controls of average stature. Results showed no evidence of serious psychosocial or academic disadvantage, before, during or, indeed, after puberty, in these youngsters. Although mean intelligence quotient (IQ) values between groups was significantly different this, again, was of no clinical import. Height, on its own, explained only 2% of the variance in IQ, emphasizing the need always to look beyond P values and consider the effect size.

The Wessex data merely confirmed other reports that socio-economic factors, rather than stature, best predict psychosocial and academic outcome . As others have found, although short children would have preferred to be taller, and reported more bullying than taller peers, neither appeared to impact on school performance or self-esteem

Such findings suggest that the stigmatized individual is able to call upon self-protective cognitive mechanisms that serve to leave the self-esteem intact

the discrepancy between earlier and more recent research can be explained by participant selection bias. These data strongly support the notion that behavioural and social difficulties are likely to be attributed to SS, even where these are largely unrelated. Parents and physicians alike can be reassured that, for most, SS is unlikely to be a burden, now or in the future

conclusions GHD children are at higher risk for social difficulties and anxiety disorders, even greater than those with ISS. With GH therapy through to final adult height, these risks appear to be lessened and remain so through adulthood after GH discontinuation. Whether this is a direct effect of GH on the hypothalamic-pituitary axis or by increased social value associated with greater height is a question for further studies to answer. effects of GH therapy on GHD children that expand beyond the increase in final adult height and these factors should be taken into consideration when they are prescribed for these children

Ethical considerations In the absence of clear pathology, physical or psychological, GH therapy for short but otherwise normal children raises issues as to the ethics of so-called ‘cosmetic’ or ‘plastic endocrinology’ Discussions range from whether such children deserve treatment, whether SS is a medical or a social condition One argument in support of GH therapy is based on the notion that medicine is primarily concerned with the relief of suffering, regardless of the aetiology .

As Brook suggests, it is much more important for a short child to acquire coping skills than to buy inches through pharmacological means. The widespread use of GH, as a first line of treatment, risks perpetuating a climate of opinion where SS is unacceptable, both to parents and society of the condition

They should bear in mind, however, that where the SS is familial , treatment will not prevent SS from recurring in subsequent generations There is a danger that the short child who has unrealistic expectations as to the benefits of treatment may be frustrated and disappointed by what is perceived as ‘treatment failure

Short stature, per se, is clearly not a disease, but is commonly perceived to be associated with social and psychological disadvantage. The assumption, widely held by pediatricians that short children are likely to be significantly affected by their stature, has been founded largely on older, poorly designed clinic-based studies and laboratory investigations of beliefs about the association between stature and individual characteristics. In contrast, data from more recent and better designed clinic- and community- based studies show that, in terms of psychosocial functioning, individuals with short stature are largely indistinguishable from their peers, whether in childhood, adolescence or adulthood.

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