Personality functioning: the influence of stature

Referral pattern of children with short stature to a pediatric endocrine clinic in Kuwait

BACKGROUND

The aim of the study was to describe the referral pattern, baseline characteristics, and etiological profile of children referred with short stature in Kuwait.

METHODS

This is a cross-sectional retrospective review of children referred to the Endocrine Clinic with short stature. Short stature was defined as height or length below the 3rd centile or <-2 standard deviation score (SDS).

RESULTS

A total of 221 children were referred with no gender difference (p=0.346). Almost one fifth of these children had normal stature. Median (interquartile) age was 7.7 (4.7, 10.3) years and mean height SDS was -2.67 (0.68). The most common diagnoses were normal variants of growth, growth hormone deficiency (GHD).

CONCLUSIONS

Our study highlights the need to improve the referral process in order to avoid unnecessary investigations and alleviate parental anxiety. There is no gender bias in short stature referrals in Kuwait. There is a need of further investigation of short stature in the region.

[How do Affected Children and Adolescents Experience their Short Stature, and what is the Point of View of their Parents?]

How do Affected Children and Adolescents Experience their Short Stature, and what is the Point of View of their Parents? Despite a large number of publications on the psychosocial situation of short statured children and their parents only a few qualitative studies focus on the perspective of the affected families. Within the European QoLISSY study ("Quality of Life in Short Stature Youth") an instrument to assess the health related quality of life of short statured children was developed. The aim of this project was to examine the self-perceived quality of life of the children themselves in comparison to their parents' perspective. During the development of the QoLISSY instrument, focus groups were conducted as a first step of this study. A total of 23 short statured children and 31 parents participated and discussed their experiences in separate groups with trained moderators. The discussions were analyzed qualitatively und results were used to generate a first list of items for the questionnaire to be developed. While parents focused on socio-emotional problems, children talked much more about their growth hormone treatment and problems in their social environment. In comparison to other studies children rated their quality of life worse than their parents. Not only medical treatment but also a psychological and socio-emotional intervention seems to be indicated.

Associations between Psychological Problems and Quality of Life in Pediatric Short Stature from Patients' and Parents' Perspectives

Short stature has been associated with psychosocial impairments, but whether treatments and achieved height impact on health-related quality of life (HrQoL) and psychological functioning of children/adolescents is still controversial. This study aimed to examine the effects of height deviation and treatment status on psychosocial adaptation outcomes and to identify clinical and psychosocial determinants of internalizing/externalizing problems in a large cohort of short statured children/adolescents from seven European countries. Participants were 345 children aged 8–18 years with a clinical diagnosis of short stature and 421 parents of 4–18 year-old patients. Children and parents reported on psychological problems (Strengths and Difficulties Questionnaire), generic (KIDSCREEN) and condition-specific HrQoL (QoLISSY). According to analyses of covariance, children/adolescents with current short stature presented more parent-reported internalizing problems and lower self- and parent-reported condition-specific HrQoL, compared to patients with an achieved height above -2SD. Treated children self-reported better HrQoL than the untreated group. Hierarchical regression analysis showed that, rather than height–related clinical variables, children’s sex, younger age and poorer HrQoL were the best predictors of psychological problems, explaining 39% of the variance in patient- and 42% in parent-reported internalizing problems, and 22% of the variance in patient- and 24% in parent-reported externalizing problems. Treatment status also moderated the negative links between patient-reported HrQoL and internalizing problems, explaining 2% of additional variance. These results suggest that children with current short stature are at greater risk for internalizing problems. Routine assessment of HrQoL in pediatric healthcare may help identify children for referral to specialized psychological assessment and intervention.

[Living with achondroplasia- how do young persons with disproportional short stature rate their quality of life and which factors are associated with quality of life?]

OBJECTIVE

Presently, little is known aqout the quality of life (QoL) as well as the strengths and difficulties of young people with achondroplasia. This study describes these patient-reported indicators and identifies possible correlates.

METHOD

At the invitation of a patient organization, a total of 89 short-statured patients aged 8 to 28 years and their parents participated in this study. QoL was assessed cross-sectionally with both generic and disease-specific instruments and the Strengths and Difficulties Questionnaire (SDQ) as a brief behavioral screening. In addition to descriptive analyses, patient data were compared with a reference population. Hierarchical regression analyses reflecting sociodemographic, clinical, and psychological variables were conducted to identify correlates of QoL.

RESULTS

QoL and the strengths and difficulties of young patients with achondroplasia did not differ substantially from a healthy norm sample. However, the participants reported more behavioral problems and limitations in their physical and social QoL compared to patients with another short stature diagnosis. Strengths and difficulties, height-related beliefs, and social support correlated significantly with QoL. Adding psychological variables to the regression model increased the proportion of variance explained in QoL.

CONCLUSIONS

Young persons with achondroplasia did not differ in their QoL and strengths and difficulties from healthy controls. Characteristics such as height appear less important for the self-perceived QoL than are strengths and difficulties and protective psychosocia~factors.

Short Stature: Is It a Psychosocial Problem and Does Changing Height Matter?

Some proponents of recombinant human growth hormone (rhGH) treatment in growth hormone-sufficient children cite height, as an isolated physical characteristic, as being associated with psychosocial morbidity. Others question the reliability of the evidence underpinning the quality-of-life rationale for treatment as well as the bioethics of rhGH treatment. The following questions are addressed: (1) Is short stature an obstacle to positive psychosocial adjustment? and (2) Does increasing height with rhGH treatment make a difference to the person's psychosocial adaptation and quality of life? Three clinical case examples are used to illustrate the complexities associated with decision-making surrounding rhGH use.

Understanding the impact of statural height on health-related quality of life in German adolescents: a population-based analysis

Improving health-related quality of life (HrQoL) is one aim of growth hormone treatment for short-statured patients. Yet, evidence of the relationship between height and HrQoL is inconclusive, especially for young people. This study investigates the association of height and HrQoL in the general German adolescent population. A total of 6646 adolescents and 6388 parents from the German Health Interview and Examination Survey for Children and Adolescents (KIGGS) were included in the analysis. An analysis of covariance was used to evaluate the effect of height deviation on HrQoL as assessed with the KINDL-R in adolescent self-report and parent-report, taking into account sociodemographic and health-related variables. Height was found to be a weak predictor of HrQoL in both adolescent-report and parent-report. Short and tall adolescents did not substantially differ from the normal statured. Sociodemographic and health-related variables failed to significantly interact with height. In contrast, psychosocial variables contributed to the explained HrQoL variance.

CONCLUSION

Height does not appear to be a strong determinant of HrQoL on the population level. These results suggest that the height gain in short stature treatment may not be the most important objective. Contrary to prevalent stereotypes, short adolescents can experience a high HrQoL.

Assessing the quality of life of health-referred children and adolescents with short stature: development and psychometric testing of the QoLISSY instrument

BACKGROUND

When evaluating the outcomes of treatment in paediatric endocrinology, the health-related quality of life (HrQoL) of the child is to be taken into consideration. Since few self-reported HrQoL instruments exist for children with diagnosed short stature (dSS), the objective of this study was to develop and psychometrically test a targeted HrQoL instrument for use in multinational clinical research.

METHODS

The target population were short stature (height<-2 SDS) children and adolescents (age 8-12 and 13-18 years) with a diagnosis of growth hormone deficiency (GHD) or idiopathic short stature (ISS), differing in growth hormone treatment status. Focus group discussions for concept and item generation, piloting of the questionnaire with cognitive debriefing, and instrument field testing with a retest were conducted simultaneously in five countries. After qualitative and preliminary quantitative analyses, psychometric testing of field test data in terms of reliability and validity including confirmatory factor analyses (CFA) was performed.

RESULTS

Following item generation from focus group discussions, 124 items were included in a pilot test with a cognitive debriefing exercise providing preliminary feedback on item and domain operating characteristics. A field test with 268 participants showed high internal consistency reliabilities (alpha 0.82-0.95), good correlations with generic measures (up to r=.58), significant known group differences (e.g. in height: F=32, df 244, p<0.001) and an acceptable CFA model fit suggesting construct validity of the three-domain core structure with 22 items, supplemented by three mediator domains with 28 items.

CONCLUSIONS

The QoLISSY questionnaire is a promising step forward in assessing the impact of dSS on HrQoL. It is based on items generated from the subjective experience of short stature children referred for endocrine investigation, is validated for use in five languages and it is easy to administer in clinical and research settings.

Debate: idiopathic short stature should be treated with growth hormone

In this paper we outline the case for and against the treatment of idiopathic short stature with growth hormone. Drs Ambler and Fairchild argue that many of those with 'idiopathic' short stature are not 'short, normal children' and will ultimately receive molecular diagnoses. They also argue that there is a subset of children who suffer negative psychosocial consequences of their stature for whom growth hormone therapy is effective. Growth hormone has a very good safety record and is likely to be as cost-effective in idiopathic short-stature as in some other conditions that are currently funded. Dr Wilkinson counters that short stature is not associated with physical or psychological illness, and that there is no evidence that growth hormone improves psychological or physical wellbeing. Moreover, growth hormone for idiopathic short stature represents a form of enhancement rather than treatment, and is not a fair use of resources. Socially mediated disadvantage should be treated by attention to prejudice and not by hormone treatment.

Regional prevalence of short stature in Saudi school-age children and adolescents

Objective. To assess the magnitude of regional difference in prevalence of short stature in Saudi children and adolescents. Subjects and Methods. A representative sample from three different regions of the Kingdom of Saudi Arabia (KSA) (North, Southwest, and Center) was used to calculate the prevalence of short stature (standard deviation score less than −2) in children 5 to 17 years of age. Results. There were 9018 children and adolescents from 5 to 17 years of age (3366, 2825, and 2827 in the Northern, Southwestern and Central regions, resp.) and 51% were boys. In both school-age children and adolescents, there was a significantly higher prevalence of short stature in the Southwestern than in the Northern or the Central region (P < 0.0001). Conclusion. The finding of significant regional variation between regions helps in planning priorities for research and preventive measures.

Clinical review: Lessons learned from the hGH era

Today, many medical interventions that begin as treatments for disease often expand into therapies that reduce disability, lessen disadvantage, or even confer advantage. Forces that propel profitable drugs, devices, and procedures dominate over considerations of efficient and equitable distribution of resources. This dominance is fueled by industry-physician collaborations often biased by prior assumptions, reliant on surrogate outcomes, and advantageous to marketing. Interventions are justified by "medicalization" of physiologic variations (e.g. short stature) as defects or disease, and nudged into "standard practice" by key opinion leaders. The story below of recombinant human growth hormone (hGH) treatment of short stature is one vivid example, but others (e.g. expansion of drug treatment to "optimize" cholesterol profiles, bone health, psychological well-being) can be found throughout medicine. In the new obesity era, lessons learned from the hGH era will be needed to keep the field of pediatric endocrinology empowered to make the key clinical decisions, and free of unintended consequences for patients and runaway health care inflation for society.

Prevalence of short stature in Saudi children and adolescents

BACKGROUND AND OBJECTIVE

Data on stature in Saudi children and adolescents are limited. The objective of this report was to establish the national prevalence of short stature in Saudi children and adolescents.

DESIGN AND SETTING

Community-based, cross-sectional study conducted over 2 years (2004, 2005)

PATIENTS AND METHODS

The national data set of the Saudi reference was used to calculate the stature for age for children and adolescents 5 to 18 years of age. Using the 2007 World Health Organization (WHO) reference, the prevalence of moderate and severe short stature was defined as the proportion of children whose standard deviation score for stature for age was less than -2 and -3, respectively. In addition, the 2000 Center for Disease Control (CDC) and the older 1978 National Center for Health Statistics (NCHS)/WHO references were used for comparison.

RESULTS

Using the 2007 WHO reference, sample size in the Saudi reference was 19 372 healthy children and adolescents 5 to 17 years of age, with 50.8% being boys. The overall prevalence of moderate and severe short stature in boys was 11.3% and 1.8%, respectively; and in girls, 10.5% and 1.2%, respectively. The prevalence of moderate short stature was 12.1%, 11% and 11.3% in boys and 10.9%, 11.3% and 10.5% in girls when the 1978 WHO, the 2000 CDC and the 2007 WHO references were used, respectively.

CONCLUSIONS

The national prevalence of short stature in Saudi children and adolescents is intermediate compared with the international level. Improvement in the socioeconomic and health status of children and adolescents should lead to a reduction in the prevalence of short stature.

Health-related quality of life and cognitive functioning in pediatric short stature: comparison of growth-hormone-naïve, growth-hormone-treated, and healthy samples

The objective of this study was to evaluate the impact of short stature on generic health-related quality of life (HRQOL) and cognitive functioning in pediatric patients. Eighty-nine youth, 48 who were initially seen with short stature (SS group) and 41 with a history of short stature being treated with growth hormone (GHT group) and one of their legal guardians participated in the study. HRQOL and cognitive functioning were assessed using the PedsQL™ 4.0 Generic Core Scales and PedsQL™ Cognitive Functioning Scale. Comparisons were made between the study groups and with a previously obtained matched healthy sample. For the GHT group, height Z score was found to be a positive predictor of overall HRQOL while duration of GHT was found to be a predictor of physical functioning. For the SS group, the difference between midparental height Z score and height Z score was found to be a negative predictor of overall HRQOL and cognitive functioning. Comparison with the healthy sample demonstrated significant negative impact on HRQOL for child self-report and on HRQOL and cognitive functioning for parent proxy-report in both study groups. The GHT group had a significantly higher child self-reported Physical Functioning score than the SS group (effect size (ES) = 0.52, p < 0.05). In conclusion, the GHT group had slightly better HRQOL scores than the SS group, but the difference was not statistically significant. Both groups had significantly lower HRQOL and cognitive functioning scores than healthy sample. Predictors of HRQOL and cognitive functioning found in this study lend support to the use of the PedsQL™ 4.0 Generic Score Scales and PedsQL™ Cognitive Functioning Scale in routine assessment of children with short stature in order to identify children at increased risk for impaired HRQOL and cognitive functioning.

Mental health and psychosocial functioning in adolescents with esophageal atresia

PURPOSE

We examined mental health and psychosocial functioning in adolescents with esophageal atresia (EA) and searched for predictors of impaired outcome.

METHODS

The study group comprised 21 adolescents with EA and 1 or both parents. A comparison group comprised 36 adolescents from the general population. Mental health, self-esteem, psychosocial functioning, and parental/family functioning were assessed by standardized questionnaires and semistructured interviews. Physical health was assessed by growth and clinical symptoms.

RESULTS

Mental health and psychosocial functioning did not differ from the comparison group. Seven of 21 EA adolescents had special education. Dilatations of esophagus, birth weight, well-being, and maternal psychological distress were prognostic factors predicting mental health. Height, birth weight, well-being, dissociative symptoms, and family strain were prognostic factors predicting psychosocial functioning.

CONCLUSION

Adolescents with EA adjusted well, and mental health and psychosocial functioning did not differ from controls. Dilatations of esophagus and birth weight were significant predictors of mental health and psychosocial functioning.

Idiopathic short stature: management and growth hormone treatment

In the management of ISS auxological, biochemical, psychosocial and ethical elements have to be considered. In boys with constitutional delay of growth and puberty androgens are effective in increasing height and sexual characteristics, but adult height is unchanged. GH therapy is efficacious in increasing height velocity and adult height, but the inter-individual variation is considerable. The effect on psychosocial status is uncertain. Factors affecting final height gain include GH dose, height deficit in comparison to midparental height, age and first year height velocity. In case of a low predicted adult height at the onset of puberty, addition of a GnRH analogue can be considered. Although GH therapy appears safe, long-term monitoring is recommended.

Long-term psychosocial consequences of hormone treatment for short stature

AIM

To examine psychosocial functioning of young adults with idiopathic short stature or short stature born small for gestational age after growth hormone (GH) and gonadotropin-releasing hormone agonist (GnRHa) treatment in early adolescence or no intervention.

METHODS

Thirty young adults (18 treated, 12 untreated; age 17-23 years; on average 5.5 years after the end of treatment) completed questionnaires regarding perceived competence and psychological distress. They and their parents were interviewed on social circumstances, height-related psychosocial stressors and parental worries about prospects in society.

RESULTS

Height gain was on average 2.3 cm more for the treated than for the untreated group. On none of the psychosocial variables differences were found between treated and untreated participants. Compared to Dutch population norms, psychological and social functioning was normal.

CONCLUSION

GH/GnRHa treatment, with arrest of pubertal development and lower than expected effects on final height, is not observed to lead to long-term negative or positive effects. Both treated and untreated participants go well through the psychosocial transition period of young adulthood. This suggests that, in the long term and independent of hormone treatment, adequate psychosocial adjustment is expected in case of short stature.

Growing up with idiopathic short stature: psychosocial development and hormone treatment; a critical review

To facilitate decisions on interventions in medically referred children with idiopathic short stature, the research on psychosocial functioning of these children, possible risk and protective factors influencing adaptation, and effects of hormone treatment were reviewed. Parents ranked the behaviour of their children on average between normal and below normal. The magnitude of these deviations varied from small to large. Little is known about the children's self-perceived psychosocial functioning. Some risk factors were found: being teased, being juvenilised, being a boy, having a younger but taller sibling, low intelligence, and low socioeconomic status. There have been few studies on the impact of protective factors including temperament, coping strategies, and social support. On average, hormone treatment did not improve psychosocial functioning. The research shows the advantages and disadvantages of hormone treatment that must be considered when choosing a suitable intervention. It is suggested that psychosocial adjustment can be improved by focusing on factors other than height alone.

Use of growth hormone in children

The introduction of recombinant DNA-derived human growth hormone (rhGH) in the mid-1980s allowed studies to be undertaken in a number of growth disorders other than the classic indication--growth-hormone deficiency (GHD). In patients with GHD, optimizing the dose and frequency of rhGH administration, and early instigation of therapy, has led to near-normalization of final height. The use of rhGH in the treatment of Turner syndrome, Prader-Willi syndrome, intrauterine growth restriction, and chronic renal failure demonstrated the efficacy of therapy, although the increase in final height (5-7 cm) is less than that achieved in GHD. Cost-benefit implications need to be considered in the next phases of evaluating the role of rhGH therapy in these indications. To date, rhGH has only received approval for the management of idiopathic short stature in the US; as with the other wider growth indications, the lack of formal randomized, controlled trials hampers the full evaluation of efficacy, and a cautious approach should, therefore, be adopted for this particular indication. rhGH has a good safety record, although there are current concerns about the possible long-term increased risk of colonic and lymphatic malignancy, which will require monitoring through national cancer registries.

Predictors of neck pain: a cohort study of children followed up from the age of 11 to 22 years

Body height is an alleged risk factor for low back pain in adulthood, but its importance regarding non-specific neck pain is obscure during childhood and adolescence. We studied anthropometric measurements for their associations with the incidence of neck pain in a population study of 430 children who were examined five times: at the age 11-14 and 22 years. Body height and weight and the degrees of trunk asymmetry, thoracic kyphosis and lumbar lordosis were measured at every examination. The history of neck pain was obtained by a structured questionnaire at the final examination. The incidence of neck pain was defined as pain occurring in eight or more days during the past year. Short stature at 11 years of age predicted the incidence of neck pain. Adjusted for sex, the odds ratio (with 95% confidence interval) per an increment of one standard deviation of body height was 0.78 (0.62-0.97). At 22 years of age there was accordingly an inverse association between current body height and neck pain history, the odds ratio being 0.62 (0.45-0.86). Male sex was found to protect against neck pain; the odds ratio was 0.28 (0.18-0.44). Anthropometric measurements other than body height were not found to predict neck pain. The role of anthropometric factors in the development of neck pain at young adulthood seems only modest. Short stature may be a risk determinant of neck pain.

Growth Hormone Treatment of Short Stature: Status of the Quality of Life Rationale

The unlimited availability of biosynthetic human growth hormone (rhGH) has contributed to the disassociation of the treatment of short stature from its causes. The rationale for treatment has traditionally rested upon the assumption that short stature, in the extreme, may constitute a physical disability, and otherwise represents a significant psychosocial burden for the individual. This review summarizes what is known about the psychosocial aspects of short stature and the quality of life benefits of rhGH treatment. Stereotypes and assumptions about short stature are evaluated in light of empirical findings. Problems of psychosocial adjustment are relatively common in the general population. Because of the salience of short stature, and its potential to serve as a lightning rod to divert attention from other factors interfering with a healthy psychological adaptation, the clinician must be watchful of misattributions for ongoing problems, or unrealistic predictions of the benefits of taller stature. For these reasons, the clinician should consider incorporating a psychosocial component in the diagnostic evaluation to broaden potential treatment recommendations. Finally, studies of factors influencing family decisions regarding factors for and against rhGH therapy provide important clues to how clinicians might enhance the informed consent process.

Growth hormone deficiency and related disorders: insights into causation, diagnosis, and treatment

Advances in molecular biology have led to the identification of mutations within several novel genes associated with the phenotype of isolated growth hormone deficiency, combined pituitary hormone deficiency, and syndromes such as septo-optic dysplasia. Progress has also been made in terms of the optimum diagnosis of disorders of stature and their treatment. The use of growth hormone for the treatment of adults with growth hormone deficiency and conditions such as Turner's syndrome, Prader-Willi syndrome, intrauterine growth restriction, and chronic renal failure has changed the practice of endocrinology, although cost-benefit implications remain to be established.