Behavior problems and social competence in girls with true precocious puberty

BEHAVIORAL PEDIATRICS

Behavior problems and social competence in girls with true precocious puberty We report a controlled standardized behavioral assessment o f 33 girls with true precocious puberty using the Child Behavior Checklist. Although a majority o f the girls were reported not to have behavior problems, many were reported to have a dysphoric adjustment to their condition. Twenty-seven percent o f the girls with true precocious puberty scored >2 SD above the mean on the Total Behavior Problem scale 10 times the expected prevalence rate. They also scored significantly higher (P < 0.01) than matched controls on both the internalizing or "overcontrolled symptom" and externalizing or "'undercontrolled symptom" scales. Forty-eight percent scored >2 SD above the mean on the Social Withdrawal scale. The high prevalence o f reported problem behaviors in this sample may be related directly or indirectly to the precocious maturation mediated by biologic, psychologic, social, and environmental variables. Although elevated levels of sex steroids may directly contribute to increased aggressive and hyperactive behaviors, they may also be modified by social and environmental factors. (J PEDIATR 106:156, 1985)

William A. Sonis, M.D., Florence Comite, M.D., Jerome Blue, Ph.D., Ora H. Pescovitz, M.D., Charles W. Rahn, M.S.W., Karen D. Hench, R.N., B.S.N., Gordon B. Cutler, Jr., M.D., D. Lynn Loriaux, M.D., Ph.D., and Robert P. Klein, Ph.D. Minneapolis, Minnesota, and Bethesda, Maryland

have described the developmental patterns and problems of Children with precocious puberty, defined as the development before age 9 years of secondary sex characteristics in children. 7 In general, most of these children grow to adulthood without problems. Two behavior problems seem to occur in children experiencing sexual precocity: social difficulties related to age/appearance dyssynchrony and moodiness. The descriptions of these P R E V I O U S R E P O R T S j-6

From the Division o f Child Psychiatry, University o f Minnesota," the Developmental Endocrinology Branch and the Child and Family Research Section, Laboratory o f Comparative Ethology (LCE), National Institute o f Child Healt h and Development; and the Laboratory o f Developmental Psychology, National Institute o f Mental Health. Researched while Dr. Sonis was a Medical Staff Fellow, CFRS, LCE, National Institute o f Child Health and Human Development. Submitted for publication Jan. 30, 1984; accepted June 15, 1984. Reprint requests: William A. Sonis, M.D., Division o f Child Psychiatry, Box 95 Mayo, University o f Minnesota Medical School, 420 Delaware St., S.E., Minneapolis, M N 55455.

156

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developmental problems, however, are based on individual case reports or analysis of semistructured interviews of primarily retrospective experience from small; clinically heterogenous populations without controls. Because of the lack of well-designed studies of the personality and adjustment of children experiencing precocious puberty, we decided to verify previous findings utilizing more rigorous methods. CBCL CBP LHRH~ TPP

Child Behavior Checklist Child Behavior Profile Luteinizing hormone releasing hormone analog True precocious puberty

We report a standardized behavioral assessment of behavior problems and social competence using the Child Behavior Checklist s in girls with true precocious puberty and in an equivalent number of controls matched on background characteristics.

METHODS All children participating in this study were evaluated as part of an approved National Institute of Child Health and

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Behavior in girls with true precocious puberty

15 7

Human Development (NICHD) protocol to halt or reverse pubertal maturation using a synthetic luteinizing hormone releasing hormone analog? Children were evaluated using the criteria described by Comite et a12 Most, but not all, of the children studied were subsequently given the experimental medicine LHRH~. The sample consisted of 33 girls* aged 6 to 11 years (mean age 8.1 years). According to the 1975 version of the Hollingshead scale, lc mean parental socioeconomic status was 5.48, or middle class. Twenty-seven girls were white, three were black, two were Hispanic, and one was Oriental. The etiologic breakdown of the diagnosis of TPP in our sample is listed in Table I. At the time of presentation 55% of the girls had height and weight >95th percentile. H Pubertal maturation and development ranged from Tanner stage II to V. Bone age was advanced by 2 to 5 years over chronologic age. At the time their parent was asked to fill out the CBCL, 76% of the girls had not begun LHRHa treatment. The child's parents were asked to fill out the CBCL as a routine part of the protocol. This is a 120-item parental report of children's behavior problems and social competence. The CBCL and the scoring norms were developed at the National Institute of Mental Health (NIMH) using 1200 children from the Washington, D.C, area. The Social Competence section consists of seven domains; the Behavior Problem section consists of 113 items. The Social Competence items are scored according to both the number and relative competence of the individual activities in each domain. The items in the Behavior Problem section are scored 0, 1, or 2 (where 0 is considered "not true" of a particular child and 2 is considered "almost always true." If possible; the parents accompanying the child were approached in the first few days of the child's initial hospitalization. They were told that we were interested in learning about the psychologic consequences, if any, of having a chronic disorder such as precocious puberty. Families whose primary language was not English were excluded. The checklists were then hand checked and scored for omissions or errors. Interrater reliability for coding the CBCL was >0.95 for each child. The Child Behavior Profile is generated from the CBCL and consists of three social competence scales (Activities, Social Activities, School), eight or nine behavior problem scales (depending on the child's age and sex), and two second-order factors (Internalizing o r Externalizing scales). 12,t3 In its broadest nosologic interpretation, the Internalizing Scale is thought to represent "overcontrolled

Table I. Composition of sample by diagnostic category

The sample was stratified to match the age and sex combinations of the CBP scoring program. Separate analyses were conducted for the Behavior Problem and Social ComPetence sections of the CBCL. For all scales on the CBP an individual item analysis was completed to assess the salience of each individual item to the scalel Many of the girls with TPP were reported to have problem behaviors. More than a fourth (27%) had a Total Behavior Problem score between 71 and 100, which represents the uppermost 2% of a normal distribution (i.e., >98th percentile) (Figure). Girls with TPP scored significantly higher than matched controls on the Total Behavior Problem score as well as on both the Internalizing and Externalizing scales. They also scored significantly higher than matched controls on all of the scales that are part of the Internalizing broad-band factor: Depressigrr, Social Withdrawal, Somatic Complaints, and Schizoid/Obsessive . Forty-five percent of the girls scored >2 SD above the mean on 1EheSocial With-

*Elevenboyswerealso includedin the sample;onlyfivehad true sexual precocity. These data are not includedin the discussionbecause their numberwas too small to draw statisticalinferences.

*The T score is a normalizedstandardscore multipliedby 10, with 50 added to the product. A score is expressedon a scale of 0 to 100, with T scores >70 or <30 representing2 SD abovethe meanof 50.

Ideopathic Hypothalamic hamartoma Without CNS symptoms With CNS symptoms Other CNS pathologic findings McCune-Albright syndrome Familial Total

n

%

22

67

2 0 3 4 2 33

6 0 9 12 6 100

or neurotic symptoms" (e.g., worry, withdrawal, nail biting, or similar behaviors) and the Externalizing Scale is thought to represent "undercontrolled or conduct disturbance symptoms" (e.g., lying, stealing, fighting, and similar behaviors). The social competence items are summed to get a Total Social Competence score, and the behavior problem items are summed to get a Total Behavior Problem Score. The Social competence and the behavior problem scales are expressed as both percentile and T scale scores..8, ~4 Each patient was matched to a control by age, sex, race, and socioeconomic status from the sample used to standardize the CBCL. The mean patient T scores were compared with the mean control T scores using a paired comparison t test for all of the scales on the Behavior Problem section of the CBP. The significance level was set at P < 0.01. RESULTS

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Sonis et al.

The Journal of Pediatrics January 1985

35

3025O3 ,< ',.D 2 0 -

~

15-

Z

113-

Legend ~2] PATIENT NmCONTROL

0

~ 0-60 61-70 71-100 T SCOREINTERVALS

Figure. Total Behavior Problem scores in girls 6 to 11 years of age with true precocious puberty.

drawal scale, and almost one third (30%) had similar scores on the Somatic Complaint scale. On the broad-band Externalizing factor, two of five scales, Hyperactive and Aggressive, were significantly elevated compared with those of the matched controls. Almost one third (30%) of the girls were reported to have Scores >2 SD above the mean on the Sex Problem scale. Slightly more than one q u a r t e r (27%) of the girls were reported t ~ have scores above the 98th percentile on the Aggressive scale. Five (15%) girls and three (9%) girls scored >2 SD above the mean on the Hyperactive and Cruel subscales, respectively (Table II). To test whether parental attributional bias accounted for the group differentiation, we derived T scores for both patient and control samples using the scoring program for 12- to 16-year-old girls. Because parents m a y h a v e different assumptions and thresholds for reporting adolescent behaviors, scoring the children with precocious puberty using the adolescent norms should decrease their Behavior Problem scores if their behaviors are attributed to "adolescence." Twenty-three percent of the patients scored above the 98th percentile on the Total Behavior Problem scale. Slightly more than one fourth (28%) of the girls had a Total Behavior Problem score >2 SD above the mean. Girls with TPP scored significantly higher than the controis on all Behavior Problem scales except Cruel. Additional analyses were performed to determine which individual items within the narrow-band factors may have contributed to the significant group differentiations. To assess this, we developed a method of item analysis. First we summed the number of times all items in each scale were scored on each narrow-band factor. This number was then divided by the number of items in the scale to find the mean number of children scored per item. The standard

deviation of the mean was then calculated in the usual manner and rounded to the next highest integer. This method served to identify those items with a higher frequency of positive scores than the group average of all items within each factor (Table III). For each of the narrow-band factors we then compared salient items for the girls with TPP to salient items for the controls. Each item was then placed into one of three categoriesi those items that were salient only for the patients, only for the Controls, and for both the patients and controls. In this manner we could isolate thoSe items that Contributed to the strength of our significant group differences in the patients. Ten items characterized the 6- to 11-year-old girls with TPP on the Internalizing factor: clings to adults, feels worthless, sulks a lot, overtired, aches or pains, headache, stomach ache, sleeps less than most children, repeats certain acts over and over, and strange behaviors, including unpredictability; Six items characterized those same patients on the Externalizing factor: can't sit still, daydreams, cries a lot, teases a lot, temper trantrums, and whining. Fifteen percent of tile girls with TPP scored lower than the 2nd percentile on the Total Social Competence scale. Matched controls were not available for this section of the CBCL. Instead, the scores of the patients were compared against the T score mean of 50. Using a one-sample t test, the girls showed significantly less cOmpetence in social activities than the normative sample mean. This scale includes such items as the number of organizations in which they participated and frequency of contacts with friends. DISCUSSION Overall, the girls with TPP could be described as troubled, depressed, aggressive, socially withdrawn, and moody. The difficulties these behaviors may engender were reflected in the Social Competence section, in which girls with TPP were reported to be less socially active and to have fewer peer activities. Although many problem behaviors were reported by parents, to view these children as psychiatrically disturbed and in need of psychiatric treatment is a misinterpretation of our findings. The CBCL and instruments such as the Conners Teachers Checklist ~5 and the Behavior Problem Checklist ~6are designed to record items of behavior and to organize them into factor-relevant scales that may be similar to but not identical with clinical diagnosis. The results of the CBCL must be interpreted in light of a child and family who are attempting to cope with multiple stressors--biologic, psychologic and social. The behavioral "breakdown" reported may reflect the child's mechanisms

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Behavior in girls with true precocious p u b e r t y

Table IlL Hyperactive scale

Table IL Behavior Problem score Index

Internalizing (n = 33) Depressed Social Withdrawal Somatic Schizoid/Obsessive Externalizing (n = 33) Hyperactive Sex Problems Delinquent Aggressive Cruel Total

15 9

Number o f positive items on Behavior Checklist

Control

Mean

SD

Mean

SD

df

t

63.4 62,7 67.3 64.2 61.4 61.2 63.5 64.0 60.7 64.1 61.0 62.9

8.3 7.6 9.2 8.5 6.7 10.7 8.9 9.1 5.3 9.7 6.3 9.9

50.2 57.5 57.3 58,6 56,8 48.8 56.5 59.6 59.2 56.7 57,6 48.3

10.5 4.5 4.6 5.2 3.8 9.8 3.5 7.4 4.6 5.1 4.1 10.8

64 64 64 64 64 64 64 64 64 64 64 64

5.29* 3.18" 5.24* 2.99* 3.22* 4.61" 3,96* 2.04 1.12 3.67* 2.41 5.36*

]'P < 0.01. for maintaining homeostasis in an abnormal environment.tv The stresses that impinge on these children and their families can be conceptualized as progressing from the generic to the specific. Repeated hospitalizations, absence from school, the cost of medical treatment, and the intrafamilial restructing that often occurs in chronic illness have a generic quality that cuts across the specific illness. In this respect there may be general noncategorical effects on psychologic growth and adjustment that are independent of the child's condition. The noncategorical effects seem to be reflected in the Internalizing factor on the CBCL. Other studies ~8'~9using the same instrument (CBCL) demonstrated significant differences between chronically ill children and controls on the Total Behavior Problem score, the Internalizing scale, and the Social Withdrawal scale. We found a similar pattern in the girls with TPP. However, there may also be specific or categorical effects related to the endocrine disorders of growth and development, such as precocious puberty. In addition to the noncategorical effects of chronic illness reflected in the high Internalizing scale scores, girls with TPP also scored high on the Externalizing scale and the Aggressive and Hyperactive scales. This is a different pattern than previously demonstrated in other groups of chronically ill children. Children with short stature do not differ from controls on any externalizing scale18; children with Turner syndrome score significantly higher than controls on the Externalizing and Hyperactive scales only. Thus there appears to be a syndrome specificity in the pattern of scale elevations. These children need to cope with an age/appearance dyssynchrony that modifies the response of their social milieu. Adults expect tall or short children to perform

Acts young Cannot concentrate Hyperactive Confused Daydreams Disobedient at school Teased* Impulsive* Disliked Poor school work Clumsy Perfers young children* Speech Stares Total

11 23 23 9 24 12 25 28 10 13 13 27 8 9 235

Total positivescores/number items = mean number children/item = 235/ 17 = 17 with SD = 8. *Salient item.

tasks that are commensurate with their height age rather than their chronologic or developmental age. 2~ This also holds true for peers, who often tease and ridicule these children. As part of their age/appearance dyssynchrony, these children may have an abnormal body image, tack self-confidence, and may prefer either to be by themselves or to seek the company of their height-matched rather than age-matched peers. A unique and very specific problem encountered by children with TPP is the abnormal timing of sexual maturation, with its ensuing biologic and social complications. Studies in animals support the influence of sex steroids on central nervous system differentiation 2~ and observed behavior? 2 However, the precise human behavioral and psychobiologic effects remain to be elucidated? 3 Moreover, the direct influences of the sex steroids on behavior may be modified by social and environmental factors. This may account for the high prevalence of social withdrawal reported in this study; if the child is experiencing environmental stress because of an age/appearance dyssynchrony, withdrawal and lack of involvement in peer social activities might be used as a coping mechanism. Certain artifacts of method may have influenced our findings. To some degree the sample is biased by selection factors related to participation in a National Institutes of Health study. Families participating in an N I H study must be willing to traveLto Bethesda, Maryland, for treatment, which may involve several long trips each year. There may also be a referral bias. Patients evaluated and treated at N I C H D must be referred by a physician who knows about the research at N I H .

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It is also possible that there are parental reporting biases. Parents who seek a medical treatment focused primarily on social issues, attempting to change the nonlife-threatening condition of body appearance, may be more sensitive to "behavioral breakdown" than those parents who do not seek treatment, They may also have an attributional bias about the behaviors of children who are biologically adolescent, and may report behaviors believed to be associated with this phase of life (moodiness, isolation, cyclical changes in behavior associated with menstrual periods). W e do not believe that attributional biases account for the significant group differentiation, however, because rescoring the patients and controls as adolescents strengthened rather than weakened our findings. In summary, girls with precocious puberty were reported to exhibit more behavioral problems and to be less socially competent than peers matched for age, sex, race, and socioeconomic status. Based on the Total Behavior Problem score, the prevalence of disturbed behavior in girls with T P P is at least four times greater than expected. Withdrawn, depressive, isolative, and aggressive behaviors dominate. Our findings confirm and elaborate the work previously published in this area. W e examined and quantified the adjustment of girls with T P P in a more systematic fashion than reported previously. A majority of the girls were reported not to have behavioral problems; however, a large minority have a dysphoric and stressful adjustment. Additional observational self-report measures in other settings and with nonexperimental populations will be added to ascertain the factors responsible for the problems experienced by many of these children. We thank the nursing staff on 9 West for their valuable assistance in this project; Barbara Wright for assistance in typing the manuscript; and the staff of the Child and Family Research Section for their comments. REFERENCES

1. Hampson JG, Money J: Idiopathic sexual precocity in the female. Psychosom Med 18:16, 1955. 2. Money J, Hampson JG: Idiopathic sexual precocity in the male. Psychosom Med 18:1, 1955. 3. Conner DV, McGeorge M: Psychological aspects of accelerated pubertal development. J Child Psychol Psychiatry 6:161, 1965. 4. Money J, Alexander D: Psychosexual development and absence of homosexuality in males with precocious puberty. J Nerv Mental Dis 148:111, 1969.

The Journal o f Pediatrics January 1985

5. Money J, Walker PA: Psychosexual development, maternalism, promiscuity, and body image in 15 females with precocious puberty. Arch Sex Behav 1:45, 1971. 6. Solyom A, Austad CC, Sherick I, Bacon GE: Precocious sexual development in girls: The emotional impact on the child and her parents. J Pediatr Psychol 5:385, 1980. 7. Williams RH: Textbook of endocrinology. Philadelphia, 1981, WB Saunders, pp 379-381. 8. Achenbach TM, Edelbrock CS: Behavior problems and competencies reported by parents of normal and disturbed children aged four through sixteen. Monogr Soc Res Child Dev 44(serial no 188):1, 1981. 9. Comite F, Cutler Jr G, Rivier J, Vale WW, Loriaux DL, Crowley WF: Short-term treatment of idiopathic precocious puberty with a long-acting analogue of leutinizing hormone releasing hormone. N Engl J Med 305:1546, 1981. 10. Hollingshead A: Four factor index of social status. New Haven, Conn., 1975, Yale University Press. 11. National Center for Health Statistics: NCHS growth curves for children. Washington, D.C., DHEW publication no. (PHS) 78-1650, p 37. 12. Achenbach TM! The child behavior profile. I. Boys aged 6-11. J Consult Clin Psychol 46:478, 1978. 13. Achenbach TM, Edelbrock CS: The child behavior profile. II. Boys aged 12-16 and girls aged 6-11 and 12-16. J Consult Clin Psychol 47:223, 1979. 14. Edwards AL: Statistical methods for behavioral sciences. New York, 1961, Holt Reinhart & Winston, pp 111-113. 15. Conners CK: A teacher rating scale for use in drug studies in children. Am J Psychiatry 6:884, 1969. 16. Quay HC: Measuring dimensions of deviant behavior: The behavior problem checklist. J Abnormal Child Psychol 5:277, 1977. 17. Chandler LA, Lundahl WT: Empericat classification of emotional adjustment reactions. Am J Orthopsychiatry 53:460, 1983. 18. Gordon M, Crouth C, Post EM, Richman RA: Psychosocial aspects of constitutional short stature: Social competence, behavior problems, self-esteem and family functioning. J PEDIATR 101:447, 1982. 19. Sonis W, Levine J, Blue J, Cutler GB, Loriaux L, Klein R: Turner's syndrome and hyperactivity: A neurodevelopmental model. (Submitted for publication.) 20. Brackbill Y, Nevill DD: Parental expectations of achievement as affected by children's height. Merrill-Palmer Q 27:429, 1981. 21. MacLusky N J, Naftolin F: Sexual differentiation of the central nervous system. Science 211:1294, 1981. 22. Ehrhardt AA, Meyer-Bahlburg HFL: Effects of prenatal sex hormones on gender-related behavior. Science 211:1312, 1981. 23. Rubin RT, Reinisch JM, Haskett RF: Postnatal gonadal steroid effects on human behavior. Science 211:1318, 1981.