Psychosocial Short Stature Clinical Presentation

  • Author: Andrew P Sirotnak, MD; Chief Editor: Caroly Pataki, MD  more...
 
Updated: Feb 17, 2015
 

History

Medical literature on psychosocial short stature (PSS) has consistently described children with a history of abuse or neglect and emotional deprivation as the key historic factor in making this diagnosis. Early case reports describe the hospitalization of such children, observation of bizarre behaviors, relatively benign physical examinations, and subsequent endocrine system testing.

Several authors have suggested that the following historic factors are important in making the diagnosis of classic PSS:[3]

  • Psychological disturbance is present.
    • Bizarre behaviors centered on food and water acquisition, despite seemingly adequate caloric and fluid intake and its availability (polyphagia, polydipsia, hoarding food, gorging and vomiting, eating from garbage bin, drinking from toilet, stealing food)[4]
    • Sleep disturbances (insomnia, night wandering)
    • Abnormal behaviors (withdrawal, apathy, anxiety, irritability, temper tantrums, shyness, accident proneness, self-injury)
    • Developmental delays (speech retardation, cognitive retardation, psychomotor retardation)
  • The caregiver appears to have some psychopathology, and the relationship with the child appears or is known to be abnormal. The following can apply to mothers or caregivers and/or the environment:
    • Depression
    • Anxiety
    • Personality disorders
    • Domestic violence or marital instability[5]
    • Substance abuse
    • Absent spouse or father of child
    • Myriad of other child abuse–associated issues involving poverty, poor education, generational abuse, and neglect
  • Abnormal endocrine function is present but normalizes when the child is removed from the unsafe and nonnurturing environment.[6]
  • Malnutrition or inadequate caloric intake alone is not demonstrated to be the primary cause of the growth failure. However, steatorrhea is often observed in individuals with type II PSS.
  • Diagnosis of PSS is confirmed by the removal of the child from the unsafe or nonnurturing environment and observation of the following with time:[7]
    • Demonstration of catch-up growth
    • Improvements in behaviors
    • Normalization of hormonal disturbances
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Physical

Physical examination of the infant or child with PSS reveals short stature; height less than the third percentile for chronologic age of the child is the most common and important physical examination finding of PSS. The disorder may be mistaken for primary or idiopathic GH deficiency.[8] Many, but not all, children with PSS are underweight for height; a few children with PSS may be overweight for height. Neurologic examination findings other than those from the mental status examination are usually normal.

  • Lung and cardiac examinations are important in excluding organic causes of growth failure, such as cystic fibrosis or heart defects.
  • Protuberant abdomen and hepatomegaly, which often are found in children who are malnourished, can be observed in individuals with PSS.
  • Perform skin examination for signs of past or chronic abuse (eg, scars, burns, pattern injury) and signs of nutritional or vitamin deficiency.
  • Perform examination of genitals and anus for evidence of past or chronic sexual abuse in any patient with child abuse or neglect.
  • A neurologic examination to exclude organic causes of bizarre behaviors is usually performed.
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Causes

Psychological factors of emotional deprivation have been demonstrated to cause transient GH deficiency in children with PSS. Nutritional deprivation or general caloric deprivation alone is not a major causal factor. The underlying cause of this deprivation by the caregiver can be determined only after the child is removed from the home and a multidisciplinary investigation of the family environment is completed. As in many cases of child abuse and neglect, the reason for the maltreatment may never be determined nor completely explained.

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Contributor Information and Disclosures
Author

Andrew P Sirotnak, MD Professor and Vice Chair of Faculty Affairs, Department of Pediatrics, University of Colorado School of Medicine; Department Head, Child Abuse and Neglect, Director, Child Protection Team, The Children's Hospital

Andrew P Sirotnak, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Chet Johnson, MD Professor of Pediatrics, Associate Director and Developmental-Behavioral Pediatrician, KU Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies; Assistant Dean, Faculty Affairs and Development, University of Kansas School of Medicine

Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

References
  1. Deltondo J, Por I, Hu W, et al. Associations between the human growth hormone-releasing hormone- and neuropeptide-Y-immunoreactive systems in the human diencephalon: a possible morphological substrate of the impact of stress on growth. Neuroscience. 2008 Jun 2. 153(4):1146-52. [Medline].

  2. Rotoli G, Grignol G, Hu W, Merchenthaler I, Dudas B. Catecholaminergic axonal varicosities appear to innervate growth hormone-releasing hormone-immunoreactive neurons in the human hypothalamus: the possible morphological substrate of the stress-suppressed growth. J Clin Endocrinol Metab. 2011 Oct. 96(10):E1606-11. [Medline].

  3. Money J. The syndrome of abuse dwarfism (psychosocial dwarfism or reversible hyposomatotropism). Am J Dis Child. 1977 May. 131(5):508-13. [Medline].

  4. Tarren-Sweeney M. Patterns of aberrant eating among pre-adolescent children in foster care. J Abnorm Child Psychol. 2006 Oct. 34(5):623-34. [Medline].

  5. Duche DJ. [Consequences of family violence on children's health]. Bull Acad Natl Med. 2002. 186(6):963-9; discussion 969-70. [Medline].

  6. Albanese A, Hamill G, Jones J, et al. Reversibility of physiological growth hormone secretion in children with psychosocial dwarfism. Clin Endocrinol (Oxf). 1994 May. 40(5):687-92. [Medline].

  7. Stanhope R, Wilks Z, Hamill G. Failure to grow: lack of food or lack of love?. Prof Care Mother Child. 1994 Nov-Dec. 4(8):234-7. [Medline].

  8. Sandberg DE, Colsman M. Assessment of Psychosocial aspects of short stature. Growth, Genetics and Hormones. June 2005. 21(2):[Full Text].

  9. Gloebl HJ, Capitanio MA, Kirkpatrick JA. Radiographic findings in children with psychosocial dwarfism. Pediatr Radiol. 1976 Feb 13. 4(2):83-6. [Medline].

  10. Blizzard RM, Bulatovic A. Syndromes of psychosocial short stature. Pediatric Endocrinology. 1996. 83-93.

  11. Fazil Q. Dwarfism: Medical and psychosocial aspects of profound short stature. Psychiatr Bulletin. 2006. 30:[Full Text].

  12. Green WH, Campbell M, David R. Psychosocial dwarfism: a critical review of the evidence. J Am Acad Child Psychiatry. 1984 Jan. 23(1):39-48. [Medline].

  13. Inokuchi M, Hasegawa T. [Deprivation dwarfism]. Nippon Rinsho. 2006 May 28. Suppl 1:102-4. [Medline].

  14. Lifshitz F, Tarim O, Smith MM. Nutritional growth retardation. Pediatric Endocrinology. 3rd ed. 1996. 103-20.

  15. Northam EA. Neuropsychological and psychosocial correlates of endocrine and metabolic disorders--areview. J Pediatr Endocrinol Metab. 2004 Jan. 17(1):5-15. [Medline].

  16. Patton RG, Gardner LI. Short stature associated with maternal deprivation syndrome: disordered family environment as cause of so-called idiopathic hypopituitarism. Endocrine and Genetic Diseases of Childhood and Adolescence. 2nd ed. 1975. 77-87.

  17. Swanson H. Index of suspicion. Case 3. Diagnosis: failure to thrive due to psychosocial dwarfism. Pediatr Rev. 1994 Jan. 15(1):39, 41. [Medline].

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Growth curves of 5 children with psychosocial short stature are depicted. In each instance, the increase in the slope of the curve occurred simultaneously with removal from the adverse home environment. The asterisk (*) notes the time of this removal.
 
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