PEDIATRICS Vol. 115 No. 2 February 2005, pp. 516-517 (doi:10.1542/peds.2004-2625)
Height and Social Adjustment: In Reply
William M. Bukowski, PhDDepartment of Psychology and Centre for Research in Human Development
Concordia University
Montreal, QC, Canada H4B 1R6
Robert B. Noll, PhD
Children's Hospital of Pittsburgh Departments of Pediatrics, Psychiatry, and Psychology
University of Pittsburgh
Pittsburgh, PA 15213
Caroline Fung, PA-C
Department of Psychiatry
University at Buffalo
State University of New York
Buffalo, NY 14222
David E. Sandberg, PhD
Departments of Psychiatry and Pediatrics
University at Buffalo
State University of New York
Buffalo, NY 14222
Although we are grateful to Dr Kemp for his interest in our study,1 we would like to respond to several issues raised in his letter. We assert that the industry-sponsored studies2,3 cited to support Kemp's view that patients with short stature exhibit academic underachievement, behavior problems, and reduced social competency relative to norms are limited by several fundamental problems. First, no evidence was provided that participants in either study were representative of the cohort referred to pediatric endocrinologists at the 27 recruiting centers of the Genentech-sponsored National Cooperative Growth Study. Without details regarding selection factors, prevalence estimates of adjustment problems are meaningless. Second, it was reported that IQs for the patient groups fell in the high-average range, whereas scholastic achievement was average.2 The authors interpreted the disparity between the 2 as indicative of academic underachievement. A critical analysis of the methods selected suggests an alternative conclusion. The measure of IQ that was selected overestimates intelligence, whereas the measure of academic achievement underestimates performance. Thus, the relatively high rate of academic "underachievement" is likely an artifact of the battery of psychoeducational tests selected.
Third, Kemp concludes from the second National Cooperative Growth Study report3 that apparent improvements in behavioral adjustment associated with growth hormone treatment provides evidence of a preexisting disability and that treatment ameliorates these problems. Unfortunately, the research-design flaws of that study undermine any such conclusion. D.E.S. and W.M.B. (with others) have detailed these weaknesses elsewhere.4 It is notable that Stabler et al3 failed to demonstrate that increases in relative height were related to adjustment. This dissociation has been reported elsewhere.5,6 Kemp also failed to cite epidemiologically oriented clinic-based studies, which do not detect clinically significant problems of psychosocial adaptation or self-concept among youths or young adults with short stature.5,7–9 In the case of 1 study cited,8 Kemp is mistaken when he refers to that sample as "not referred." Most importantly, no research has shown clear linkages between giving growth hormone, changes in height, and subsequent changes in adjustment. If growth-promoting medical therapies are offered to improve the individual's quality of life in the present or future, then it is incumbent on clinicians and clinical researchers to incorporate a comprehensive psychosocial assessment in the evaluation of patients. Although the parameters of such an evaluation have been outlined,10 to the best of our knowledge they have not been adopted in the clinical decision-making algorithm, and no clinical research data support this model.
Kemp's contention that population-based samples of short children include children who are insufficiently short to test hypotheses concerning height and psychosocial adjustment is not supported by the evidence. A number of clinic-based studies have also failed to demonstrate that psychological adjustment declines with increasing severity of short stature.5,8,11 In fact, 1 study found the opposite to be true: relatively taller children with short stature (ie, <5th percentile) exhibited significantly more behavior problems than relatively shorter youths (range: –4.0 to –1.6 height SD).8
Although we recognize that the subsample of very short youths (ie, less than –2.25 SDs) in our study was not large (n = 22), statistical power was sufficient in that design to detect effect sizes large enough to be interpreted as evidence of significant impairment in peer relations. Moreover, the height range of this group (–4.67 to –2.25 SDs; mean: –2.68 SD) is comparable to that of patients involved in the referenced postmarketing studies.2,3
In contrast to Kemp, we believe that obtaining data from peers about peer relationships is the methodology of choice. The measures used in our study have a long history of use in developmental psychology and have the distinction of being stable over time and predictive of future psychological functioning across multiple domains.12 We acknowledge that this type of research is challenging to complete, but responses from peers on widely used measures of social relationships are considered to be the methodological "gold standard."
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- Sandberg DE, Bukowski WM, Fung CM, Noll RB. Height and social adjustment: are extremes a cause for concern and action?
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[Abstract/Free Full Text] - Rekers-Mombarg LT, Busschbach JJ, Massa GG, Dicke J, Wit JM. Quality of life of young adults with idiopathic short stature: effect of growth hormone treatment. Dutch Growth Hormone Working Group. Acta Paediatr. 1998;87 :865 –870[CrossRef][Web of Science][Medline]
- Noeker M, Haverkamp F. Adjustment in conditions with short stature: a conceptual framework. J Pediatr Endocrinol Metab. 2000;13 :1585 –1594[Web of Science][Medline]
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- Rubin KH, Bukowski WM, Parker JG. The peer system: interactions, relationships and groups. In: Eisenberg N, ed. The Handbook of Child Psychology. New York, NY: Wiley; 1998
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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Related articles in Pediatrics:
- Height and Social Adjustment
- Stephen F. Kemp
Pediatrics 2005 115: 515-516.[Extract] [Full Text]
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