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Visser-van Balen et al reported (in the first paper) on
the psychological consequences of combined growth hormone
(GH)/gonadotropin-releasing hormone agonist (GnGHa) treatment in a multicenter,
randomized-controlled study conducted in early pubertal youths (ages 11 to 13
years; Tanner breast stage 2 or 3 for girls, Tanner genital stage 2 or 3 for
boys) with a diagnosis of either idiopathic short stature (ISS; 17 girls, 9
boys) or born small for gestational age (SGA; 8 girls, 4 boys). The authors
explained the unusual predominance of girls as reflective of the combination of
SS and relatively early puberty is more common in girls that boys. Participants
had a height SDS below –2, or between –1 and –2 with a predicted adult height
SDS below –2. In the second paper, the authors examined patients’ and parents’
motivations in choosing to participate in this study.
Adolescents in the
treatment group were administered GH (4 IU [1.33mg]/m2 BSA, SQ, daily)
and GnRHa (3.75 mg, IM depot, every 4 weeks). At baseline, 1, 2, and 3 years
after beginning treatment, adolescents and their parents (mostly mothers) in
both groups completed questionnaires to assess the psychosocial functioning of
the adolescents by completing a standardized assessment evaluating adolescents’
health-related development, current height-related stressors, and parental
concerns about their child’s future behavioral and emotional functioning;
perceived current and expected adult height; global intelligence; perceived
competence, psychological distress, and personality characteristics.
At baseline, a minority
of parents (28%) reported their child experienced teasing or juvenilization by
peers; however, a higher proportion (44.5%) anticipated their child would face
challenges in the labor market as an adult (39% of boys, 48% of girls) and 39%
expected their child to have lower prospects of finding a spouse (77% of boys,
17% of girls, p<0.01). Parent reports of behavioral and emotional functioning
suggested a statistically significant excess of problems. In contrast,
adolescents’ self-reports of emotional distress and self-concept did not
systematically differ from normative values. Differences in psychosocial
variables at baseline were not detected between the treatment and control
groups, ISS and SGA subgroups, or children whose parents reported
stature-related psychosocial stressors. With regard to motivation to
participate, patients were categorized into 4 subgroups based on the presences
of height-related psychosocial stressors, parental worries about their child’s
current behavior and about future prospects, and patients’ self-reported
problems in psychosocial functioning.
During treatment, parent
reports of current stigmatization and worries over future challenges did not
change, and did not differ between the treatment and control groups. The same
was not true for perceptions of the child’s behavioral and emotional
functioning. In contrast, self-perceived scholastic and athletic competence in
the treatment group significantly decreased over time (ie, became more
negative), while that of the adolescents in the control group increased
(moderate effect size). Trait anxiety decreased for adolescents in the control
group, but remained at approximately the same level for adolescents in the
treatment group. The authors noted that, despite these statistically
significant effects, there was considerable overlap of scores between the 2
groups and one apparent outlier in the treatment group.
As noted above, parents perceived an excess of
psychological adjustment problems in their children, however this difference
was not matched by the children’s self-reports. As such, the investigators
concluded that it is primarily the parents’ perceptions of problems (current
or anticipated) that drive the process in search of a medical intervention. The
adolescents wanted to gain height, but their underlying motivation remains
unclear.
Visser-van Balen H, Geenen R, Moerbeek M, J et al. Psychosocial functioning
of adolescents with idiopathic short stature or persistent short stature born
small for gestational age during three years of combined growth hormone and
gonadotropin-releasing hormone agonist treatment. Horm Res. 2005;64:77
- 87.
Visser-van Balen H, Geenen R, Kamp GA, Huisman J, Wit JM, Sinnema G. Motives
for choosing growth-enhancing hormone treatment in adolescents with idiopathic
short stature: a questionnaire and structured interview study. BMC Pediatr .
2005;5:15.
Editor’s Comment: My initial reading of this
study left me somewhat confused: why would researchers look for effects of
combined GH/GnRHa treatment on psychological outcomes when the long-term
benefits of GnRHa on adult height had not yet been realized? In fact, the
addition of GnRHa could have slowed growth. The answer to this puzzle is that
this study was not about psychological effects of changes in height, but rather
was examining the influence of arrested pubertal development on adolescents’
psychosocial adaptation. An implicit assumption justifying GnRHa as an adjunct
to GH treatment is that the benefits of taller adult height outweigh the
potential psychosocial liabilities of delayed or arrested pubertal development.
The findings of a more negative self-concept in the treatment group give reason
for pause. There are many reasons for viewing these findings as tentative, not
the least of which is the high rate of missing data by the third year of
treatment, confounding interpretation of the findings.
It was not so long ago that delayed puberty (in
males, at least) was considered a significant threat to the individual’s
psychosocial development.1,2 Perhaps the time has come to consider a
head-to-head comparison of the short- and long-term psychological benefits of
on-time puberty versus taller adult stature.
Few studies
directly examine parents’ motivations in seeking care for their child,3,4
and no studies of the children themselves. This study begins the process of
filling an important gap in knowledge. It has long been known that there is
limited concordance in the reports of parents and their children when a
description of the child’s psychosocial adaptation is in question,5
a clear limitation in employing “parent-proxy only” assessments. Another
methodological cautionary note derives from the likelihood of overestimating
the incidence of emotional/behavioral problems when comparing clinical samples
to population norms. The authors correctly pointed out that norms for a
commonly used behavior problem checklist, the Child Behavior Checklist, are biased
towards mental health and not representative of the general population.6
This study documented that future (even more than
current) worries about the short child, are on the minds of parents when they
seek treatment for their child. To the extent that this finding is replicated
in independent and larger studies, it suggests that parents’ decisions may
hinge predominantly upon the negative stereotypes of foreclosed life options
for adults with short stature. The empirical basis for these stereotypes are
shaky.7,8 Accordingly, it is the clinician’s responsibility to
check for, and to correct these faulty assumptions when present, lest they
engender self-fulfilling prophecies.
David E. Sandberg, PhD
References - (linked to  )
- Rosenfeld
RG, Northcraft GB, Hintz RL. A prospective, randomized study of testosterone
treatment of constitutional delay of growth and development in male adolescents. Pediatrics.
1982;69:681 - 687.
- Wilson
DM, Kei J, Hintz RL, Rosenfeld RG. Effects of testosterone therapy for
pubertal delay. Am J Dis Child 1988;142:96
- 99.
- Singh
J, Cuttler L, Shin M, Silvers JB, Neuhauser D. Medical decision-making
and the patient: understanding preference patterns for growth hormone therapy
using conjoint analysis. Med Care. 1998;36(Suppl):AS31 - AS45.
- Finkelstein
BS, Singh J, Silvers JB, Marrero U, Neuhauser D, Cuttler L. Patient attitudes
and preferences regarding treatment: GH therapy for childhood short stature. Horm
Res. 1999;51(Suppl):67 - 72.
- Achenbach TM, McConaughy SH, Howell
CT. Child/adolescent behavioral and emotional problems: Implications of
cross-informant correlations for situational specificity. Psychol Bull. 1987;101:213
- 232.
- Sandberg DE, Meyer-Bahlburg HF, Yager TJ. The Child Behavior
Checklist nonclinical standardization samples: should they be utilized
as norms? J
Am Acad Child Adolesc Psychiatry. 1991;30:124 - 134.
- Sandberg DE, Colsman M. Assessment of psychosocial aspects of short stature. Growth
Genet Horm. 2005;21:18 - 25.
- Sandberg DE, Colsman M, Voss LD. Short stature and quality of life: A
review of assumptions and evidence. In: Pescovitz OH, Eugster E, eds. Pediatric
Endocrinology: Mechanisms, Manifestations, and Management. Philadelphia:
Lippincourt, Williams & Wilkins, 2004:191-202.
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