The psychosocial consequences of short stature: a review of the evidence

Heightism, growth hormone treatment, and social functioning: a holistic approach to a persistent clinical challenge

PURPOSE OF REVIEW

Use of recombinant human growth hormone (rhGH) treatment to increase height in children with non-growth hormone deficient short stature is becoming more common. Yet, the evidence to support the notion that augmenting height directly leads to increased well being, specifically psychosocial well being, is inconsistent, with high-quality evidence lacking.

RECENT FINDINGS

Review of recent studies demonstrates that the association between height augmentation and psychosocial well being is complex. The direct contribution of height to well being may be less than the current model of clinical care of short stature assumes. Rather, the new studies provide evidence to support a role for psychosocial factors, including height-related beliefs, social support, and coping skills, in promoting psychosocial well being, specifically quality of life and self-esteem.

SUMMARY

Clinical care of short stature would benefit from incorporating a holistic model of care that considers psychosocial interventions in addition to, or instead of, rhGH treatment.

Growth hormone treatment in children with short stature: impact of the diagnosis on parents

OBJECTIVES

This prospective multicenter study aimed (1) to examine changes in parent-reported health-related quality of life (HRQOL) of children with short stature and the effects of the children's condition on parents themselves within the first year of human growth hormone (hGH) treatment and (2) to predict effects on parents based on main and interaction effects of children's HRQOL and increase in height.

METHODS

A total of 110 parents of children aged 4-18 years, diagnosed with idiopathic growth hormone deficiency, small for gestational age, or idiopathic short stature, were recruited from 11 participating German pediatric endocrinologists and asked to fill out the short stature-specific Quality of Life in Short Stature Youth (QoLISSY) Questionnaire before hGH treatment was initiated and one year later.

RESULTS

Negative effects of the children's short stature on the parents decrease over time, independent of diagnosis and treatment status. Furthermore, treatment status and height increase moderated the links between children's improved HRQOL as perceived by their parents and decreased caregiving burden.

CONCLUSIONS

Based on the children's improved HRQOL and the parent's decrease in caregiving burden, patient-reported outcomes that consider parental and child's perspectives should be considered when deciding on hGH treatment for children.

Health-Related Quality of Life, Stress, Caregiving Burden and Special Needs of Parents Caring for a Short-Statured Child-Review and Recommendations for Future Research

Children with short stature can experience a range of burdens due to their chronic condition. However, little is known about parents' experiences dealing with their child's short stature and the potential caregiving burdens and concerns they may face. We aim to review the literature on health-related quality of life (HRQOL), caregiving burden, and special needs among parents caring for a child with isolated growth hormone deficiency (IGHD) or idiopathic short stature (ISS). Using pre-defined inclusion and exclusion criteria, we systematically searched for literature using PubMed and Web of Science from its inception to December 2022. We identified 15 articles assessing HRQOL, special needs, or caregiving burdens in parents of IGHD/ISS children. The main problems included concerns about the future, organizational issues, side effects from growth hormone treatment, and social stigmatization. Furthermore, two studies assessed parents' special needs to cope with caregiving stress, mainly the dialogue between them and their families or parent support groups. This review outlines parental burdens, needs, and resources when caring for an IGHD/ISS child. Furthermore, it provides information about previously used measures appraising parents' special needs and underlines the need for disease-specific measurements.

Caregiving burden and special needs of parents in the care of their short-statured children - a qualitative approach

PURPOSE

To explore caregiving burden, health-related quality of life (HRQOL), stress, and individual resources of parents in the care of children with isolated growth hormone deficiency (IGHD) or idiopathic short stature (ISS).

METHODS

Focused interview analysis of previously, within the Quality of Life in Short Stature Youth (QoLISSY) project, conducted structured focus group discussions (n=7) with parents (n=33) of children with IGHD/ISS aged 4 to 18 years were performed.

RESULTS

26 out of the 33 parents reported mental stress due to their child's growth disorder. Social pressure and stigmatization were also mentioned as being demanding. Some parents reported having trouble with human growth hormone (hGH) treatment. Several parents wished for parent support groups with other like-minded parents of short-statured children.

CONCLUSION

For physicians, it is essential to understand the parents' caregiving burden, stress, and individual resources in caring for IGHD/ISS children. If an impaired HRQOL is detected, psychological intervention for these parents may be scheduled, and coping mechanisms may be discussed. Furthermore, it seems essential for parents to be educated by their healthcare provider about the possible side effects of hGH treatment or to know where to find evidence-based information about it.

Quality of Life of Children and Adolescents with Short Stature: The Twofold Contribution of Physical Growth and Adaptive Height-Related Cognitive Beliefs

This study aimed to examine the health-related quality of life (HrQoL), coping, height-related beliefs, and social support of children/adolescents with short stature, the sociodemographic, clinical, and psychosocial variables associated with HrQoL, and the moderating role of sociodemographic and clinical variables on the associations between psychosocial variables and HrQoL. 114 Portuguese children/adolescents with short stature, aged 8-18 years old, completed the Quality of Life in Short Stature Youth questionnaire and the Satisfaction with Social Support Scale. Regression analyses explained 54% of the variance of HrQoL, with significant main effects of current height deviation and height-related beliefs, and a significant interaction effect between beliefs and diagnosis. Results suggest that a multidisciplinary therapeutic approach, not only focused on hormone treatment to boost physical growth, but also including psychosocial interventions focused on the modification of height-related beliefs, may contribute to improve the HrQoL of pediatric patients with short stature.

Approach to the Patient: Safety of Growth Hormone Replacement in Children and Adolescents

The use of recombinant human growth hormone (rhGH) in children and adolescents has expanded since its initial approval to treat patients with severe GH deficiency (GHD) in 1985. rhGH is now approved to treat several conditions associated with poor growth and short stature. Recent studies have raised concerns that treatment during childhood may affect morbidity and mortality in adulthood, with specific controversies over cancer risk and cerebrovascular events. We will review 3 common referrals to a pediatric endocrinology clinic, followed by a summary of short- and long-term effects of rhGH beyond height outcomes. Methods to mitigate risk will be reviewed. Finally, this information will be applied to each clinical case, highlighting differences in counseling and clinical outcomes. rhGH therapy has been used for more than 3 decades. Data are largely reassuring, yet we still have much to learn about pharmaceutical approaches to growth in children and the lifelong effect of treatment.

Lack of Catch-Up Growth with Growth Hormone Treatment in a Child Born Small for Gestational Age Leading to a Diagnosis of Noonan Syndrome with a Pathogenic PTPN11 Variant

Background

Growth hormone (GH) treatment increases the adult height of short children born small for gestational age (SGA). Catch-up growth is associated with a younger age, shorter height, and prepubertal status at the onset of GH treatment. We report a 12 11/12-year-old girl born SGA who received GH for 5 years without catch-up growth and was diagnosed with Noonan Syndrome (NS).

Results

A 5-year-and-9-month-old 46, XX girl born SGA was started on GH treatment at a dose of 0.32 mg/kg/week. Her midparental target height is 158.6 cm. Endocrine work up showed an IGF-1 level 69 ng/ml (Normal (N): 55–238 ng/ml), IGFBP3 2.6 mg/L (N: 1.9–5.2 mg/L), TSH 3.2 mIU/L (N: 0.35–5.5 mIU/L), and a normal skeletal survey. Height was 96 cm (0.1%; Ht SDS −2.9), weight 14 kgs (1%; Wt SDS −2.3), and Tanner 1 breast and pubic hair were observed. Due to the poor catch-up growth on GH treatment, she was referred to Genetics to elucidate genetic or syndromic causes of short stature. She was noted to have posteriorly rotated ears and slight down slanting of the palpebral fissures. Genetic findings showed a heterozygous pathogenic variant in PTPN11 (c.922A > G (p.Asn308Asp)) diagnostic for NS. This finding is de novo given negative parental testing. She was noted to have a heterozygous missense variant of unknown significance (VUS) in FGFR3: c.746C > A (p.Ser249Tyr). FGFR3 is associated with multiple skeletal dysplasias including thanatophoric dysplasia, achondroplasia, and Crouzon syndrome and hypochondroplasia. Clinical correlation is poor for these syndromes.

Conclusion

Diminished catch-up growth and response to GH treatment in a child born SGA led to the diagnosis of NS. The concomitant diagnosis of SGA and NS may have affected the responsiveness of this child to the growth promoting effect of GH treatment.

Etiologies, profile patterns and characteristics of children with short stature in Jordan

OBJECTIVES

Childhood growth influences their social and psychological behavior, and abnormal growth may reflect underlying pathological etiologies. It is important to diagnose children with short stature as early as possible to be able to manage treatable causes. We aim to study etiologies and characteristics of short stature in children in Jordan.

METHODS

This is a cross-sectional retrospective review of the medical records of children diagnosed with short stature at a referral university hospital. Clinical characteristics, auxological, laboratory, and radiological investigations were collected and analyzed.

RESULTS

Among a total of 551 children diagnosed with short stature, the number of boys was significantly higher than girls, 304 (55.2%) and 247 (44.8%), respectively with a p-value of 0.015. Average age at presentation for all patients was 10.24 ± 3.23, with no significant difference between boys and girls. Pathological etiology was higher than normal variants 55.7 and 44.3%, respectively with p=0.007. Constitutional delay of growth and puberty (CDGP) was the most frequent cause in the normal variant group, 59.8%. Among the pathological group, the most common etiology was growth hormone deficiency (32.2%) with mean age of presentation of 9.40 years and was not significantly different from the age in other etiological groups, 9.44 years and p=0.931.

CONCLUSIONS

Growth monitoring of children should start at an early age for boys and girls. Referral to the pediatric endocrine clinic should be considered when growth problems are suspected for accurate diagnosis and etiology profiling.

Maternal anxiety in relation to growth failure and growth hormone treatment in children

Health disorders in mothers and their children are subject to mutual influences arising from the nature of mother-child relationship. The aim of the study was to analyze the issue of anxiety amongst mothers of short children in aspect of growth hormone (GH) therapy in Poland.The study was based on a group of 101 mothers of originally short-stature children: 70 with GH deficiency treated with recombinant human GH and 31 undergoing the diagnostic process, without any treatment. Collected medical data included the child's gender, height and weight, chronological age, bone age delay, and GH therapy duration. For all children the height SDS (standard deviation score of height) and BMI SDS (standard deviation score of body mass index) were calculated. The Spielberger State-Trait Anxiety Inventory (STAI) was used to evaluate anxiety levels among the recruited mothers. Obtained results revealed low trait anxiety levels in all mothers, with no statistically significant differences between the groups. State anxiety levels were significantly higher in mothers of children without diagnosis and treatment than in mothers of children receiving appropriate therapy. Significantly lower levels of maternal state anxiety were observed during the first stage of the GH therapy, and they were further reduced in mothers of children treated for more than 4 years.Growth failure in Polish children is not associated with high maternal anxiety as a personality trait, but lack of diagnosis and lack of appropriate treatment seem to generate high levels of anxiety as a transient state in mothers. The initiation of GH therapy induces a substantial reduction of maternal state anxiety, and the duration of this treatment causes its further decrease. Mothers of short children undergoing diagnostic process could benefit from psychological support, but it seems to be unnecessary when their children are treated with GH.

Validation of the Greek version of the Quality of Life in Short Stature Youth (QoLISSY) questionnaire

Background The Quality of Life in Short Stature Youth (QoLISSY) questionnaire is a condition-specific instrument for measuring the health-related quality of life (HRQoL) in short statured children/adolescents from patients' and parents' perspectives. The aim of this study was to investigate the psychometric properties of the Greek version of the QoLISSY questionnaire. Methods The original European QoLISSY scales were translated into Greek following the guidelines for linguistic validation and applied to 184 dyads of children 8-18 years old and their parents, as well as to 14 parents of children 4-7 years old in Greece. The field testing responses to the Greek version of QoLISSY were analyzed. Results The qualitative analysis of the Greek data provided results consistent with the European sample. The subsequent field test showed acceptable internal consistency (Cronbach α between 0.67-0.93) and high test-retest reliability (intraclass correlation coefficients [ICC] ≥0.70). Correlations with the generic KIDSCREEN questionnaire indicated good convergent validity. Confirmatory factor analysis (CFA) also yielded acceptable results. Higher HRQoL for taller children suggests that QoLISSY was able to detect significant height-related differences. Conclusions The Greek version of the QoLISSY questionnaire is psychometrically sound and its use is recommended in further clinical research to ascertain the impact of short stature (SS) and treatments in Greek children/adolescents and families.

The Effect of Gonadotropin-Releasing Hormone Analogue on Final Adult Height in Children with Idiopathic Short Stature

OBJECTIVE

To assess final adult height (FAH) in children with short stature treated with gonadotropin-releasing hormone analogue (GnRHa).

METHODS

All patients with idiopathic short stature (ISS) with normally timed puberty and a Tanner stage between 2 and 3, who achieved their FAH between 2005 and 2015, were included in this clinical historical cohort study. Height gain, FAH, and mid-parental height of 28 children with ISS who received GnRHa treatment for 1.8 ± 1.0 years to delay their puberty were compared to 31 untreated children.

RESULTS

The FAHs of the treated and the untreated girls were 151.3 ± 5.1 and 146.8 ± 3.8 cm (p = 0.01), respectively. The FAHs of the treated and the untreated boys were 156.4 ± 4.7 and 152.3 ± 5.7 cm (p = 0.111), respectively. The height gain in the treated and the untreated girls was 1.6 ± 7.8 and -3.6 ± 5.7 cm (p = 0.036), respectively. Height gain in the treated and the untreated boys was -5.1 ± 13.6 and -11.5 ± 8.4 cm (p = 0.171), respectively.

CONCLUSION

GnRHa therapy has a modest effect in improving FAH in adolescent females with ISS but not in boys.

A Retrospective Analysis of Patients with Short Stature in the South of China between 2007 and 2015

OBJECTIVE

To describe the demographic features of children with short stature and poor growth in the south of China and provide better guidance on clinical strategy and decisions.

STUDY DESIGN

This retrospective, chart review study analyzed children with short stature and poor growth admitted to the Department of Endocrinology of Children's Hospital of Nanjing Medical University from Jan 2007 to Dec 2015.

RESULTS

The chart review yielded 4142 patients, including 2546 boys and 1596 girls (P < 0.001); the number of patients gradually increased per year from 2007 to 2015. There was an upward trend in the average levels of height standard deviations (SDs) during the study period (P < 0.001), both in males (P < 0.001) and females (P < 0.001). Mean height SDs were smaller in females (-2.42±1.09) than males (-2.33±1.03; P = 0.01). The percentage of females admitted at normal height (33.83%) was lower than that of males (37.20%; P = 0.028). The peak age range of hospitalization in males was 10-12 years of age, while females were generally admitted earlier-8-10 years.

CONCLUSIONS

There was an increasing tendency to focus on children's height. Parents and pediatricians were recommended to pay more attention to the treatment needs of girls while avoiding excessive treatment of those who merely appear not to be tall enough without a clear medical issue related to growth, especially for boys.

Is growth hormone deficiency associated with anxiety disorder and depressive symptoms in children and adolescents?: A case-control study

AIM

Children with growth hormone deficiency (GHD) are reported to experience failure in psychological maturation, and to have a lack of self-confidence in social life, and depressive symptoms. The purpose of this study was to investigate the relation between GHD and anxiety disorders and depression in children and adolescents.

METHOD

122 children and adolescents aged 7-17, 87 receiving GHD therapy and 35 before treatment, and 122 healthy volunteers were included in the study. All participants were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version-Turkish Version (K-SADS-PL-T). Diagnoses falling outside this semi-structured interview were made with clinical evaluation based on DSM-V diagnostic criteria. Participants were also assessed using an information form, the State-Trait Anxiety Inventory for Children (STAI-C), the Social Anxiety Scale for Children-Revised (SASC-R), and the Children's Depression Inventory (CDI), and the results were subjected to statistical analysis.

RESULTS

Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD) were significantly more common in children with GHD compared to the control group (p ≤0.001 and p = 0.033, respectively). Receipt of treatment significantly reduced GAD and SAD rates in the group diagnosed with GHD (p = 0.012, and p = 0.014). Being in receipt of GH therapy also caused a significant decrease in STAIC (State) (p ≤0.001), STAIC (Trait) (p ≤0.001), SASC-R (p ≤0.001), and CDI (p ≤0.001) scale scores. Untreated subjects had more adverse scale scores than treated subjects, and treated subjects had more adverse scale scores than the control group. An increase was observed in all scale scores in the form of control group < treated group < pre-treatment group. IGF and GH-PEAK exhibited moderate negative correlation with STAIC-TRAIT, STAIC-STATE, and SASC-R, and weak negative, significant correlation with CDI (Spearman's rho p ≤0.05).

CONCLUSION

Having GHD and being in receipt of treatment resulted in lower scale scores. Children with GHD had higher GAD and SAD burdens compared to the healthy controls. The etiology of these children's existing psychiatric diseased now requires identification using more variables in psychosocial and hormonal terms.

Linking Stress and Infertility: A Novel Role for Ghrelin

Infertility affects a remarkable one in four couples in developing countries. Psychological stress is a ubiquitous facet of life, and although stress affects us all at some point, prolonged or unmanageable stress may become harmful for some individuals, negatively impacting on their health, including fertility. For instance, women who struggle to conceive are twice as likely to suffer from emotional distress than fertile women. Assisted reproductive technology treatments place an additional physical, emotional, and financial burden of stress, particularly on women, who are often exposed to invasive techniques associated with treatment. Stress-reduction interventions can reduce negative affect and in some cases to improve in vitro fertilization outcomes. Although it has been well-established that stress negatively affects fertility in animal models, human research remains inconsistent due to individual differences and methodological flaws. Attempts to isolate single causal links between stress and infertility have not yet been successful due to their multifaceted etiologies. In this review, we will discuss the current literature in the field of stress-induced reproductive dysfunction based on animal and human models, and introduce a recently unexplored link between stress and infertility, the gut-derived hormone, ghrelin. We also present evidence from recent seminal studies demonstrating that ghrelin has a principal role in the stress response and reward processing, as well as in regulating reproductive function, and that these roles are tightly interlinked. Collectively, these data support the hypothesis that stress may negatively impact upon fertility at least in part by stimulating a dysregulation in ghrelin signaling.

The Impact of Early Life Stress on Growth and Cardiovascular Risk: A Possible Example for Autonomic Imprinting?

Introduction

Early life stress is imprinting regulatory properties with life-long consequences. We investigated heart rate variability in a group of small children with height below the third percentile, who experienced an episode of early life stress due to heart failure or intra uterine growth retardation. These children appear to develop autonomic dysfunction in later life.

Results

Compared to the healthy control group heart rate variability (HRV) is reduced on average in a group of 101 children with short stature. Low HRV correlates to groups of children born small for gestational age (SGA), children with cardiac growth failure and children with congenital syndromes, but not to those with constitutional growth delay (CGD), who had normal HRV. Reduced HRV indicated by lower RMSSD and High Frequency (HF)-Power is indicating reduced vagal activity as a sign of autonomic imbalance.

Conclusion

It is not short stature itself, but rather the underlying diseases that are the cause for reduced HRV in children with height below the third percentile. These high risk children—allocated in the groups with an adverse autonomic imprinting in utero or infancy (SGA, congenital heart disease and congenital syndromes)—have the highest risk for ‘stress diseases’ such as cardiovascular disease in later life. The incidence of attention deficit disorder is remarkably high in our group of short children.

Explaining parent-child (dis)agreement in generic and short stature-specific health-related quality of life reports: do family and social relationships matter?

BACKGROUND

In the context of health-related quality of life (HrQoL) assessment in pediatric short stature, the present study aimed to examine the levels of agreement/disagreement between parents' and children's reports of generic and condition-specific HrQoL, and to identify socio-demographic, clinical and psychosocial variables associated with the extent and direction of parent-child discrepancies.

METHODS

This study was part of the retest phase of the QoLISSY project, which was a multicenter study conducted simultaneously in France, Germany, Spain, Sweden and UK. The sample comprised 137 dyads of children/adolescents between 8 and 18 years of age, diagnosed with growth hormone deficiency (GHD) or idiopathic short stature (ISS), and one of their parents. The participants completed child- and parent-reported questionnaires on generic (KIDSCREEN-10 Index) and condition-specific HrQoL (QoLISSY Core Module). Children/adolescents also reported on social support (Oslo 3-items Social Support Scale) and parents assessed the parent-child relationships (Parental Role subscale of the Social Adjustment Scale) and burden of short stature on parents (QoLISSY- additional module).

RESULTS

The parent-child agreement on reported HrQoL was strong (intraclass correlation coefficients between .59 and .80). The rates of parent-child discrepancies were 61.5 % for generic and 35.2 % for condition-specific HrQoL, with the parents being more prone to report lower generic (42.3 %) and condition-specific HrQoL (23.7 %) than their children. The extent of discrepancies was better explained by family and social relationships than by clinical and socio-demographic variables: poorer parent-child relationships and better children's social support were associated with larger discrepancies in generic HrQoL, while more parental burden was associated with larger discrepancies in condition-specific HrQoL reports. Regarding the direction of discrepancies, higher parental burden was significantly associated with parents' underrating, and better children's social support was significantly associated with parents' overrating of condition-specific HrQoL.

CONCLUSIONS

Routine assessment of pediatric HrQoL in healthcare and research contexts should include child- and parent-reported data as complementary sources of information, and also consider the family and social context.

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.

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.

Etiologies and characteristics of children with chief complaint of short stature

PURPOSE

Short stature is a very common reason for visits to pediatric endocrine clinics. It could be the first sign of an underlying disease. The purpose of this study is to investigate the etiologies and general characteristics of subjects who visited an outpatient clinic due to short stature.

METHODS

We retrospectively reviewed the medical records of 3,371 patients who visited Severance Children's Hospital with the chief complaint of short stature from 2010 to 2012. Medical history, auxological data, and laboratory tests including bone age were collected and analyzed. Chromosome studies or combined pituitary function tests were performed if needed.

RESULTS

Approximately 89.4% of the subjects with the chief complaint of short stature who visited the outpatient clinic were of normal height, and only 10.6% of subjects were identified as having short stature. Of the subject of short stature, 44.7% were classified as having normal variant short stature; that is, familial short stature (23.0%), constitutional delay in growth (17.7%), and mixed form (3.9%). Pathological short stature was found in 193 subjects (54.2%). Among pathological short stature, most common etiology was growth hormone deficiency (GHD) (38.9%).

CONCLUSION

A majority of children had a normal height. Among children with short stature, pathological short stature and normal variants occupied a similar percentage. GHD was the most common cause of pathological short stature and found in about 20% of the children with short stature. In pathological short stature, the height, height velocity, and IGF-1 level were lower than in normal variants.

How Short is Too Short According to Parents of Primary Care Patients

OBJECTIVE

Height is a physical trait on a continuum. The threshold between normal and abnormal is arbitrarily set but can potentially influence medical decision-making. We sought to examine parents' perceptions of adult heights and associated demographic factors.

METHODS

Parents of pediatric primary care patients of various heights completed a one-time survey. Parents answered the question "How short is too short?" for adult males and females. The results were summarized as median [interquartile range]. Factors significantly associated with height threshold by simple linear regression were included in a multivariable mixed effects analysis of covariance model.

RESULTS

A total of 1,820 surveys were completed (83% response rate; 1,587 females, 231 males). The median threshold height deemed too short for adult females was 56 inches [48, 59] among male respondents and 57 inches [50, 60] among females (P<.05). The median threshold height for adult males was 61 inches among males [60, 64] and females [59, 66] (P<.05). The median of male minus female heights per respondent (delta heights) was 5 [2, 7] inches. Factors found to be significant main effects in a parsimonious model were sex of the adult considered, height of respondent, sex of respondent, respondent race, primary care practice, income, and having concerns about their child's height.

CONCLUSION

Taller acceptable height thresholds were perceived by respondents who were taller, wealthier, white, female, from nonurban practices, or who had a personal concern about their child's height. Male heights were expected to be taller than female heights. Such traits may influence who is concerned and more likely to seek medical treatment for their children.

Clinical dilemmas in evaluating the short child

Concerns about a child's growth are one of the most common topics parents voice during general pediatric office visits and are a leading cause for referral to a pediatric endocrinologist. There are a variety of conditions that lead to short stature in children; however, in the absence of true pathology, idiopathic short stature and constitutional delay are the most frequent causes. This article reviews the general approach to evaluating the short child and clinical signs that should prompt further evaluation and referral. We also address the unique psychological issues that these children face and approaches to counseling families with a child with idiopathic short stature.

HRQoL of European children and adolescents with short stature as assessed with generic (KIDSCREEN) and chronic-generic (DISABKIDS) instruments

Short stature may be associated with impairments in health-related quality of life (HRQoL). This study compared the HRQoL of children/adolescents diagnosed with short stature to population norms and examined the effects of height deviation and treatment status on HRQoL.

METHOD

We cross-sectionally assessed 110 children/adolescents aged 8-18, with current short stature (height deviation ≤-2 standard-deviation (SD)) or normal height achieved since diagnosis, and 98 parents, using the generic KIDSCREEN and the chronic-generic DISABKIDS instruments.

RESULTS

Generic HRQoL of patients was similar to population norms. Patients with achieved normal height reported better chronic-generic HRQoL when untreated, while patients with current short stature reported better HRQoL upon receiving treatment. Parents reported better HRQoL for treated patients, especially for girls.

CONCLUSION

Although their HRQoL is not significantly compromised, patients diagnosed with short stature may profit from growth-hormone treatment. Specific instruments are needed to adequately assess the effectiveness of treatment.

Internet informs parents about growth hormone

BACKGROUND

Parents' knowledge influences decisions regarding medical care for their children.

METHODS

Parents of pediatric primary care patients aged 9-14 years, irrespective of height, participated in open focus groups (OFGs). Moderators asked the question, 'How do people find out about growth hormone (GH)?' Because many parents cited the Internet, the top 10 results from the Google searches of 'growth hormone children' and 'parents of children who take growth hormone' were examined. Three investigators independently performed content analysis and then reached a consensus. The results were tabulated via summary statistics.

RESULTS

Eighteen websites were reviewed, most with the purpose of education (56%) and many funded by commercial sources (44%). GH treatment information varied, with 33% of the sites containing content only about US FDA-approved indications. Fifty-six percent of the sites included information about psychosocial benefits from treatment, with 44% acknowledging them as controversial. Although important to OFG participants, risks and costs were each omitted from 39% of the websites.

CONCLUSION

Parents often turn to the Internet for GH-related information for their children, although its content may be incomplete and/or biased. Clinicians may want to provide parents with tools for critically evaluating Internet-based information, a list of prereviewed websites, or their own educational materials.

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.

Child height, health and human capital: Evidence using genetic markers

Height has long been recognized as being associated with better outcomes: the question is whether this association is causal. We use children's genetic variants as instrumental variables to deal with possible unobserved confounders and examine the effect of child/adolescent height on a wide range of outcomes: academic performance, IQ, self-esteem, depression symptoms and behavioral problems. OLS findings show that taller children have higher IQ, perform better in school, and are less likely to have behavioral problems. The IV results differ: taller girls (but not boys) have better cognitive performance and, in contrast to the OLS, greater height appears to increase behavioral problems.

Height and health-related quality of life: a nationwide population study

CONTEXT

Treatment for short stature in childhood has been recommended with the purpose of improving adult health-related quality of life (HRQoL). However, there are only limited data available concerning the consequences of body height for HRQoL in adulthood.

OBJECTIVE

Our objective was to investigate the relationship between body height and HRQoL.

DESIGN, SETTING, AND PARTICIPANTS

This national representative, cross-sectional household survey of the French general noninstitutionalized population included 8857 men and 9248 women, aged 18-50 yr, in 2003.

MAIN OUTCOME MEASURES

Scores on the eight subscales of the Medical Outcomes Study 36-item Short Form (SF-36) were the primary outcomes. Univariate and multivariate linear regression analyses were used to evaluate the effect of height on HRQoL while controlling for age and various socioeconomic variables and pathological conditions.

RESULTS

Height was found to be a very weak predictor of HRQoL both for men and women. Only heights lower than 149.2 and 136.0 cm and higher than 203.6 and 188.7 cm, in men and women, respectively, were associated with a clinically significant reduction in physical functioning. The effects of body height on other (mental and social) dimensions of HRQoL were negligible or undetectable.

CONCLUSIONS

Height appears to have minimal consequences for physical functioning and negligible effects on other dimensions of HRQoL. These results contrast with widely popularized stereotypes and common beliefs and should be carefully considered to avoid further stigmatization and unnecessary medical care of individuals who are at the lower end of the growth distribution.

Turner syndrome and sexual differentiation of the brain: implications for understanding male-biased neurodevelopmental disorders

Turner syndrome (TS) is one of the most common sex chromosome abnormalities. Affected individuals often show a unique pattern of cognitive strengths and weaknesses and are at increased risk for a number of other neurodevelopmental conditions, many of which are more common in typical males than typical females (e.g., autism and attention-deficit hyperactivity disorder). This phenotype may reflect gonadal steroid deficiency, haploinsufficiency of X chromosome genes, failure to express parentally imprinted genes, and the uncovering of X chromosome mutations. Understanding the contribution of these different mechanisms to outcome has the potential to improve clinical care for individuals with TS and to better our understanding of the differential vulnerability to and expression of neurodevelopmental disorders in males and females. In this paper, we review what is currently known about cognition and brain development in individuals with TS, discuss underlying mechanisms and their relevance to understanding male-biased neurodevelopmental conditions, and suggest directions for future research.

The benefits of growth hormone therapy in patients with Turner syndrome, Noonan syndrome and children born small for gestational age

This review will summarize the effects of growth hormone (GH) on height, body composition, bone and psychosocial parameters in children with Turner syndrome or Noonan syndrome and those born small for gestational age. The safety of GH treatment in children with these diagnoses is also reported. Despite the reported efficacy and safety of GH in these indications, however, not all children achieve their target height potential, due in some part to poor adherence to GH therapy regimens; indeed up to 50% of children are less than fully compliant with treatment. With this in mind the present and future administration of GH therapy is discussed with respect to advances being made in the presentation of GH for injection and advances in GH injection devices. It is hoped that such progress, aimed at making the administration of GH easier and less painful for the patient will improve treatment adherence and outcome benefits.

Growth hormone use in children: necessary or designer therapy?

Society often rewards the beautiful, the smart, and the intelligent. The possibility that children with idiopathic short stature (ISS) will sustain psychological damage as a result of ridicule from their peers is a concern. The desire for children to become tall adults provides a difficult quandary for parents and caregivers. Growth hormone (GH) treatment in children requires subcutaneous injections six to seven times weekly. The cost of treating with GH can be more than $52,000, and many third-party payers do not cover the cost of GH treatment. Research to date would indicate that while the administration of GH may improve final adult height in children with ISS, children treated with GH will remain short when compared with peers. More research is needed to study whether the administration of GH is beneficial for children with ISS. This article will discuss ISS and the use of GH in children.

Growth hormone: health considerations beyond height gain

The therapeutic benefit of growth hormone (GH) therapy in improving height in short children is widely recognized; however, GH therapy is associated with other metabolic actions that may be of benefit in these children. Beneficial effects of GH on body composition have been documented in several different patient populations as well as improvements in lipid profile. Marked augmentation of bone mineral density also seems evident in many pediatric populations. Some of these benefits may require continued therapy past the acquisition of adult height. With long-term therapy of any kind, the adverse consequences of treatment should also be considered. Fortunately, long-term GH treatment seems to be safe and well-tolerated. This review describes the long-term metabolic effects of GH treatment in the pediatric population and considers how these may benefit children who are treated with GH.

The influence of weight and height status on psychological problems of elementary schoolchildren through child behavior checklist analysis

PURPOSE

This study aimed to evaluate weight and height status and their relationship with psychological problems among elementary schoolchildren.

MATERIALS AND METHODS

A total of 405 schoolchildren (211 boys and 194 girls, aged: 10-13 years), living in Seoul, Korea, participated in this study. The participants were divided into 3 groups according to their weight and height standard deviation score. Psychological assessments were performed using the Korean-Child Behavior Checklist (CBCL).

RESULTS

In this study, 34.4% of boys and 32.1% of girls showed dissatisfaction with their weight, whereas 26.2% of boys and 30.2% of girls showed dissatisfaction with their height. The obese group showed higher weight dissatisfaction than the normal or underweight groups (p < 0.001). The short stature group showed higher dissatisfaction in their height than the normal group (p = 0.01). There was no significant difference in total CBCL problems score according to weight or height status. The underweight and obese groups had higher score for social problems than normal weight group (p < 0.05 respectively). There were no significant differences in each CBCL problem score by height status. As a whole, the prevalence rate of a CBCL total problems score in the clinical range was 3 percent (12/405). These children showed no difference in terms of weight or height, compared with normal students. Among the factors related, only school performance was negatively correlated with the total problems score (p < 0.01).

CONCLUSION

Approximately one-third of elementary schoolchildren were dissatisfied with their height or weight. Although their total CBCL psychological problem scores were closely related with school performance, they did not show any significant relation with height or weight status. Contrary to the general view, our study suggests that psychological problems of elementary schoolchildren may be related more with their school performance than their body physique.

Body image in adolescents with disorders of steroidogenesis

AIM

Little is known about body image in children with endocrine conditions. We evaluated body image in children with congenital adrenal hyperplasia (CAH), familial male precocious puberty (FMPP), and Cushing's syndrome (CS).

STUDY DESIGN

We compared 67 patients (41 CAH, 12 FMPP, 14 CS) age 8-18 years with 55 age-matched controls.

RESULTS

Patients expressed more weight unhappiness than controls (females: p < 0.001; males: p = 0.01). This difference remained for females after adjusting for body mass index (BMI) (p = 0.03), but not for males (p = 0.12). Unhappiness with height and age of appearance was similar between groups. In female patients, higher BMI was a significant predictor of weight unhappiness (p = 0.01).

CONCLUSION

Adolescents with CAH, FMPP, and CS are at risk for negative body image regarding weight, but not height or age of appearance. Weight unhappiness is partially related to greater weight, but factors unrelated to physical findings seem to contribute to negative body image in female patients.

Current prescribing practices and opinions about growth hormone therapy: results of a nationwide survey of paediatric endocrinologists

BACKGROUND

With the advent of several new treatment indications for recombinant hGH, endocrinologists are being asked to make some difficult decisions regarding eligibility for treatment. The purpose of this study was to summarize prevailing attitudes about GH diagnosis and treatment among paediatric endocrinologists.

METHODS

We sent surveys to all active US members of the Lawson Wilkins Pediatric Endocrine Society (LWPES) listed in the 2004-05 directory (excluding our own group of physicians). Thirty-eight per cent of the surveys were returned and 182 met eligibility for analysis. Surveys were divided into four parts: demographic data, answers reflecting current diagnosis practices for GH deficiency and treatment with GH, attitudes and clinical practice for the idiopathic short stature (ISS) diagnosis, and four case studies. Through a series of questions, we elicited the influence towards prescribing GH of current height, growth velocity, predicted height, pubertal progression and other variables. Results were entered into a Microsoft Access database and statistical evaluation was conducted.

RESULTS

Eighty-eight per cent of respondents answered 'no' to the statement that there is good consensus on who should be treated with GH and over 90% answered 'no' to the statement that secretagogue testing was the best way to determine if a child would benefit from GH. Factors listed by respondents as important for prescribing GH include: growth velocity less than the 25th percentile, target height less than the 5th percentile and pubertal stage greater than Tanner 2. Current height was also important; however, answers varied as to what height percentile indicated the need for treatment. When queried about prescribing practices for nonstraightforward cases, 62% of respondents answered that the cost of GH influenced their decision to treat, 55% responded that concerns of future unknown side-effects affected their decision and 37% noted family persistence influenced their decision. In response to queries about ISS, 82% answered that they were currently using the new indication and 69% answered that there was a need for the indication. The statement that short stature could be a disability received a 'yes' response from 78%. Answers to the four cases reflected lack of consensus, with one-third of all respondents answering that they would treat each case, one-third choosing to treat more than two of the cases and one-third treating less than two of the cases.

CONCLUSION

Endocrinologists differed in their answers about cause for treatment with GH but in general favoured use of poor growth velocity, poor target height and low IGF-1 levels as indications to treat a paediatric patient with GH.

Management of short stature with GnRH agonist and co-treatment with growth hormone: a controversial issue

Adolescent growth is the focus of several interventions aimed at increasing the amplitude of the adolescent spurt. Favorable results with GnRH agonists in precocious puberty have encouraged attempts to increase the duration of the adolescent growth spurt by delaying normal puberty in short individuals using GnRH agonists with or without growth hormone. These approaches remain highly controversial, have not been validated and approved for use by regulatory authorities and were the topic of a session at the 6th International Conference on the Onset of Puberty. Here we review the available information on the efficacy and safety of this approach. GnRH agonists, when used outside the context of precocious puberty, induce a modest gain when used for extended periods of time. Several trials have now shown that growth hormone alone can modestly increase adult height in short adolescents with idiopathic short stature or in those born small for gestational age. The association of growth hormone and GnRH agonists still lacks a definite demonstration of its additional efficacy and available results do not allow firm conclusions. In conclusion, watchful waiting or sex steroids in delayed puberty are generally the best options in short children presenting around puberty. However, long-term and adequately powered clinical trials, focusing on efficacy, safety and clinical significance are needed to fully evaluate the combination of growth hormone and GnRH agonists in short adolescents. In the meanwhile, these approaches should be considered as experimental.

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.

Turner syndrome: four challenges across the lifespan

Turner syndrome (TS) is a sex chromosome condition that occurs in approximately 1/2,500 live female births. Despite the prevalence of this chromosomal condition, the challenges these women face throughout their lives are not fully understood. This qualitative research study aimed to characterize the subjective experiences of individuals with TS throughout their lifespan, to investigate their concerns and obstacles, and to offer insight into the strengths and weaknesses of health care delivery, as they perceived them. Ninety-seven girls and women with TS and 21 parents consented to participate in this interview study. Interviews were semi-structured and open-ended in design. Questions sought to elicit responses relating to existing concerns associated with their condition and positive and negative health care experiences. Participants were divided into four age categories (childhood, adolescence, adulthood, and mature adulthood) to facilitate a comparative analysis across the age spectrum. Regardless of age, infertility was the most frequently cited concern followed closely by short stature. Sexual development and function and general health were also viewed as challenges by a number of participants in each age group. Although the relative weight of these four concerns tended to shift based upon the individual's age and life experiences, all four issues remained significant throughout the lifespan. Enhanced awareness of the evolving physical and psychological challenges faced by girls and women with TS may help health care providers (HCPs) improve the quality of life for these individuals.

Quality of life and health in children following allogeneic SCT

A total of 52 children, age 9 or over and at least 3 years (median=8) beyond SCT for leukaemia (n=32) or nonmalignant diseases, participated in a single-centre study of health and quality of life (QoL). QoL and self-esteem were assessed with SCHQ-CF87, a generic multidimensional self-report instrument, and with 'I think I am'. As a group, the children had good QoL, but were below norm in the bodily pain (P<0.05), general health and self-esteem dimensions (P<0.01). Lansky or Karnofsky function levels were at a median of 90. Sense of coherence (SOC-13) was normal and correlated with SCHQ-CF87. Most children were subjectively and objectively in good health according to a self-assessment symptom inventory or by a medical record-based scoring of late effects, although pain was commonly reported. A total of 25% of the patients were rated as having moderate to severe late effects, without considering cataracts or infertility. Neither age at SCT, gender, malignant vs nonmalignant disease, nor stature influenced QoL significantly. Children with moderate to severe chronic graft-versus-host disease or cognitive deficits had lower QoL in some dimensions. No correlation was, however, found between the physician-rated total late effects score and overall QoL. Contrarily, QoL was clearly related to the degree of self-rated symptoms.

Motives for choosing growth-enhancing hormone treatment in adolescents with idiopathic short stature: a questionnaire and structured interview study

BACKGROUND

Growth-enhancing hormone treatment is considered a possible intervention in short but otherwise healthy adolescents. Although height gain is an obvious measure for evaluating hormone treatment, this may not be the ultimate goal for the person, but rather a means to reach other goals such as the amelioration of current height-related psychosocial problems or the enhancement of future prospects in life and society. The aim of our study was to clarify the motives of adolescents and their parents when choosing to participate in a growth-enhancing trial combining growth hormone and puberty-delaying hormone treatment.

METHODS

Participants were early pubertal adolescents (25 girls, 13 boys) aged from 11 to 13 years (mean age 11.5 years) with a height standard deviation score (SDS) ranging from -1.03 to -3.43. All had been classified as idiopathic short stature or persistent short stature born small for the gestational age (intrauterine growth retardation) on the basis of a height SDS below -2, or had a height SDS between -1 and -2 and a predicted adult height SDS below -2. The adolescents and their parents completed questionnaires and a structured interview on the presence of height-related stressors, parental worries about their child's behavior and future prospects, problems in psychosocial functioning, and treatment expectations. Questionnaire scores were compared to norms of the general Dutch population.

RESULTS

The adolescents reported normal psychosocial functioning and highly positive expectations of the treatment in terms of height gain, whereas the parents reported that their children encountered some behavioral problems (being anxious/depressed, and social and attention problems) and height-related stressors (being teased and juvenilized). About 40% of the parents were worried about their children's future prospects for finding a spouse or job. The motives of the adolescents and their parents exhibited rather different profiles. The most prevalent parental worries related to the current or future functioning of their children, while a few cases were characterized by no observed motives or by psychosocial problems only reported by the adolescents themselves.

CONCLUSION

The motives for participating in a growth-enhancing hormone trial are more obvious in the parents than in the adolescents themselves. Two out of three parents report worries about the future opportunities or observe modest current psychosocial problems in their children. The adolescents want to gain height, but the motivation underlying this remains unclear. Few of the adolescents experience psychosocial problems. Our analyses revealed differences among individuals in terms of motives, which implies that in an evaluation of hormone treatment, the importance of divergent outcome variables will also differ among individuals. Effectiveness evaluations of hormone treatment to increase height and the consequential fulfillment of other goals must be awaited.

Psychological adaptation in children with idiopathic short stature treated with growth hormone or placebo

The influence of short stature on psychological adaptation in childhood and adolescence is controversial. GH is currently used to treat children with idiopathic short stature (ISS, also known as non-GH-deficient short stature). This study represents the first double-blind, placebo-controlled trial of the effects of GH on the psychological adaptation of children and adolescents with ISS, treated with GH until adult height was attained.Sixty-eight children (53 males, 15 females), 9-16 yr old, with marked ISS (measured height or predicted adult height -2.5 sd or less) received either GH 0.074 mg/kg or placebo sc three times per week until height velocity decreased to less than 1.5 cm/yr. Parents completed the Child Behavior Checklist (CBCL) and children the Self-Perception Profile (SPP) and Silhouette Apperception Technique at baseline and annually thereafter. Baseline behavioral/emotional adjustment (CBCL) and self-concept (SPP) scores for children with ISS were within the normative range. The two study groups exhibited similar behavioral and self-concept profiles (CBCL) during the first 2 yr of the study. However, CBCL behavior problems (internalizing, externalizing, and total problems) appeared to decline, in yr 3 and 4, in the GH-treated group relative to the placebo-treated group. Group differences in CBCL competency domains and the SPP were not observed at any point during the study. Short stature among children with ISS enrolled in this long-term, placebo-controlled study was not associated with problems in psychological adaptation or self-concept with the psychological instruments employed. GH treatment was associated with a trend toward improvement in problem behaviors, as measured by questionnaires (CBCL) completed by study participants' parents. It remains to be determined whether GH treatment significantly impacts adaptation, psychosocial function, or quality of life in children with ISS.

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.