Educational, psychologic, and social aspects of short stature

n

Educational, Psychologic, and Social Aspects of Short Stature Patricia

n

A. Rieser, BSN, RN, FNP-C

Children with short stature may experience academic difficulties, psychologic impairment, and emotional stress related to an underlying medical condition or social stigmatization. Educational and psychosocial problems associated with short stature often can be alleviated with appropriate interventions. Parents, health-care practitioners, and teachers should be aware of the potential academic, psychologic, and social problems related to short stature and growth delay, so they can support the short child’s normal development and intervene promptly if problems arise. J PEDIATR HEALTH CARE. (1992). 6, 325-332

he heights of approximately 2 million children in the United Statesare below the fifth percentile on a growth chart. Most short children are healthy, their size reflecting either their genetic heritage (familial short stature) or a variation of the normal growth pattern (constitutional delay of growth [CDG]). Pathologic causesof short stature and growth failure include endocrine conditions such as hypothyroidism and growth hormone deficiency (GHD); genetic conditions such as Turner syndrome (TS) and Russell-Silver syndrome; systemic diseasesthat adversely affect nutritional status or the cellular environment; and severe emotional and social deprivation (psychosocial dwarfism). Children with short stature may have problems with social and academic functioning. Many of these problems are due to social prejudice based on height and the failure of adults to treat short children in an ageappropriate manner. In addition to these external factors, evidence exists that some growth-related disorders have specific effects on neuropsychologic and cognitive functions. Awarenessof psychologic, academic,and social risks associatedwith some causesof short stature will aid parents, health-care providers, and teachers in preventing, detecting, or ameliorating potential problems. Most studies on the cognitive and psychosocial aspects of short stature in children have focused on children with GHD, TS, or CDG. GHD results from congenital or acquired hypothalamic or pituitary dysfimction. TS, also known as gonadal dysgenesis,is a genetic condition in which one of the X chromosomes in affected girls is missing or abnormal; TS is associatedwith severe short stature, undeveloped ovaries, and lack of Patricia A. Rieser, BSN, RN, FNP-C, is a clinical nurse specialist for the Division of Endocrinology at the University of North Carolina at Chapel Hill. Reprint requests: Patricia A. Rieser, FNP-C, Division of Pediatric Endocrinology, CB 7220,509 Burnett-Womack, UNC - Chapel Hill, Chapel Hill, NC 27599. 25twwa6

JOURNAL OF PEDIATRIC HEALTH CARE

pubertal development. CDG is a term used to describe children who experience poor linear growth in early childhood, but who subsequently resume a normal growth velocity, enter puberty late, and ultimately achieve an adult height consistent with their genetic potential. Intellectual capacity, academic performance, and behavioral/emotional status are the most commonly investigated areas of function of children with short stature. n INTELLECTUAL

ACADEMIC

CAPACITY PERFORMANCE

AND

The relationships among short stature, intelligence, and academicperformance have been investigated since the 1960s. Early studies were hampered by small sample sizes, wide age ranges, inconsistent diagnostic criteria, and failure to report subjects’socioeconomic status. Despite these limitations, a picture of impaired school performance in a significant number of children with growth disorders emerged and formed the basisfor current researchefforts. Studies

of Children

with

CHD

In a study of 45 children with GHD and 40 matched normal-statured controls, 43% of the GHD group had been retained in a grade in school at least once because of academic or behavioral problems (Lewis, Johnston, Silverstein, & Knuth, 1986). Data from a study that evaluated neuropsychologic profiles of 12 school-aged children with GHD indicated that 50% of thesechildren had failed a grade, compared with no grade failures in diabetic or normal-statured control groups matched for age, sex, and socioeconomic status (Ryan, Johnston, Lee, & Foley, 1988). Although the study sample was small, the results were important becausethe affected children met strict diagnostic criteria for GHD, underwent extensivepsychologic testing, and were compared both with children with chronic illness and with normal children. The children with GHD differed from controls 325

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TABLE 1 Comparisons of cognitive and affective measures for children with isolated growth hormone deficiency and multiple hormone deficiencies n

Isolated (N = 27)

Multiple (N = 15)

P

100 96 9.5

86 87 7.5

.06 NS .07

10

9.0

NS

8.4

7.0

NS

13 48%

7 15%

c.05 c.05

62

64

WISC-R Measure Verbal IQ Performance IQ Verbal comprehension factor Perceptual organization factor Freedom from distractibility factor V-P differences Incidence of V-P differences 215 points Piers-Harris General self-concept Parent Attitude Overpossessiveness From

Siegel,

1990.

Copyright

1990,

1.6 by

Springer-Verlag,

NS

1.9 Inc.

0.6 Reprinted

by

permisston. V-P, Verbal-performance.

on eight of the 16 psychologic tests administered; the largest differences were found on the measuresof academic achievement. No differences were noted among the groups on the self-concept scale, leading the investigators to conclude that low self-esteemwas not a factor contributing to academicunderachievementin the children with GHD. The authors noted that the children with GHD showed deficiencies in complex visual or constructional skills, orientation in space, long-term memory, and attention span, but that these specific cognitive deficits did not suggest generalized brain dysfunction. Researchersat Children’s Hospital of Michigan in Detroit, Michigan, and C.S. Mott Children’s Hospital in Ann Arbor, Michigan, conducted a series of studies of the cognitive, behavioral, and academic functioning of a group of short children with idiopathic GHD. These studies were prompted by clinical observations of children with GHD that differed from previous observations in which children with GHD were reported to have averageability and underachievementrelated to low self-esteemand inappropriate parenting. The Michigan group noticed that children with GHD receiving outpatient treatment for learning or behavioral problems had a high incidence of birth trauma and developmental delays, suggesting the possibility of specific learning disabilities or below averagelearning potential secondaryto prenatal or perinatal insult. These children were observed to be quiet, but not withdrawn or immature. In addition, their parents did not appear to be

5, Part 2 1992

overprotective and were supportive of their children’s independenceand age-appropriate behavior. The first Michigan study (Siegel, 1982) involved 42 children with idiopathic GHD, 27 ofwhom had isolated GHD (IGHD) and 15 of whom had multiple hormone deficiencies (MHD). Intelligence, as measured by the Wechsler Intelligence Scale for Children-Revised (WISC-R), was in the low-average range, with a high incidence of verbal-performance differences.Analysis of specific subtests suggesteddeficits in attention, concentration, sequencing, and long-term memory. Thirtyeight percent of the children with GHD had evidence of specific visual-spatial deficits. Reading achievement scoreswere close to normative values, but math scores were significantly lower than the norm. Comparison of the children with IGHD and MHD in this study revealedthat the children with MHD were more likely to have experienced developmental delays and seizures (possibly secondary to hypoglycemia related to the endocrine condition). The MHD group showed little variability on the WISC-R, with most scores falling in the low-average range. The IGHD group showed average overall intelligence, but with a high degreeof variability, which suggestedthe presence of learning disabilities. Neither group showed evidence of low self-esteem(as assessedby the Piers-Harris SelfConcept Scale) or maternal overprotection (as assessed by the Parent Attitude ResearchInstrument) (Table 1). In a 3-year follow-up study of the original sample of children with GHD, the Michigan researchersfound that 52% had significant academic problems and more than one third of them had failed at least one grade in school (Siegel & Hopwood, 1986). No differenceswere found between the underachievers and achievers with regard to sex, socioeconomic status, diagnosis, chronologic age, skeletal maturity (bone age), age at diagnosis, length of growth-hormone treatment, milestone achievement, self-concept scores, or maternal attitude scores. However, the underachievers exhibited significantly different scores on all cognitive measures.Test results were evaluated in terms of three theories that have been advancedto explain underachievement (Siegel, 1982, cited in Siegel, 1990). In 40% of the underachievers,the cognitive profiles were best explained by the low ability theory, which describesbelow-average intelligence on both verbal and performance scales. Thirty-six percent of the underachievers exhibited evidence of specific cognitive deficits (learning disabilities) and average overall intelligence (cognitive deficit theory). The remaining 24% were of averageintelligence and had no evidence of specific cognitive deficits; this is consistent with the cognitive underfunctioning theory, which postulates that poor achievement is related to environmental and psychosocial factors such as inappropriate parenting and low self-esteem.

lournal of Pediatric Health Care

Educational,

In summary, the results of the Michigan studies revealed that children with idiopathic GHD had low-average ability and that a significant number underachieved in school. Children with MHD were more likely to be intellectually compromised than those with IGHD. Some underachieving children with GHD displayed cognitive and behavioral profiles similar to those of children with attention-deficit hyperactivity disorder. Low self-esteemand inappropriate parenting were not found to play an important role in the school performance of these children. Other

Psychologic,

and Social Aspects of Short Stature

327

CHD I

I

Studies

Holmes, Hayford, and Thompson (1982) reported a 25% grade-retention rate in a sample of 56 short children with GHD, CDG, and TS. In a follow-up study (Holmes, Thompson, & Hayford, 1984), they observed that 31% of the children with GHD were retained in a grade, comparedwith only 20% of those with TS and 19% of those with CDG (Figure 1). They noted that the children who had been retained continued to achieve at a level about 6 months below their grade placement. Children who had been retained exhibited lower intelligence and achievementscoresand more behavioraland emotional problems than did short children who had not been retained. Richman, Gordon, Tegtmeyer, Crouthamel, and Post (1986) studied 24 children with CDG and reported that children’s intellectual function, academic achievement,and visual-motor integration did not differ from normal-statured controls, although five of the children with CDG had repeated a grade, compared with one of the control children. The authors did not provide an explanation for the high incidenceof grade retention but implied that social factors played an important role. A multicenter, longitudinal study of children receiving growth hormone treatment is underway. Data from the pretreatment evaluations of 142 short children (GHD, 62 children; idiopathic short stature, 60 children; TS, 20 children) indicated that within each diagnostic group, a higher than expected number of children were underachieving in at least one area (Stabler et al., 1991). In contrast, a recent British study of nonreferred children who were below the third percentile in height found no evidence of academicunderachievementthat was not related to socioeconomicstatus (Voss, Bailey, Mulligan, Wilkin, & Betts, 1991). G irls with TS exhibit the same range of intelligence asthe general population, although they are more likely to have specific cognitive weaknesses.Table 2 surnmarizes some of the studies that have evaluated cognitive and neuropsychologic function in girls with TS. Their learning problems tend to fall in the visual-spatialrealm, and poor performance in word fluency, memory, and numeric tests has been reported. Cognitive findings are

CHD TS CDG n

= Growth hormone deficiency = Turner syndrome = Constitutional delay of growth

FIGURE 1 Grade retention

by diagnosis.

‘lOrn 106

90 <5

5.25

25-75

Height Percentile Groups WISC

0

WRAT

WISC = Wechsler Intelligence Scale for Children WRAT = Wide Range Achievement Test

FIGURE 2 Association of height and IQ in U.S. children and adolescents (Cycle III subjects). From “The Effects of Growth on Intellectual Function in Children and Adolescents” by D. M. Wilson, P. M. Duncan, S. M. Dornbusch, P. L. Ritter, and R. G. Rosenfeld, 1986, in B. Stabler and L. Underwood (Eds.), Slow Grows the Child: Psychosocial Aspects of Growth Delay (p. 1431, Hillsdale, NJ: Lawrence Erlbaum Associates. Copyright 1986 by Lawrence Erlbaum Associates, Inc. Reprinted by permission.

n

independent of culture, age, karyotype, and physical stigmata (Steinhausen& Smith, 1986). G irls with TS in the study by Holmes, Karlsson, and Thompson (1986) had a high incidence of poor grades (710/o), grade retention (63%), and placement in specialclasses (59%). It is interesting to note that severallarge studieshave

Volume

328

n

Rieser

TABLE 2 Cognitive and neuropsychologic

5, Part 2 1992

functions in Turner syndrome

Year

N

Measures

Type of process

Findings

Money

1964

38

Cohen factors of the WISUWAIS

Verbal comprehension, perceptual organization, freedom from distractibility

Garron

1977

67

Cohen factors of the WlSClWAlS

Verbal comprehension, perceptual organization, freedom from distractibi I ity

Silbert et al.

1977

13

Neuropsychological battery

Steinhausen et al.

1978

8

Spatial perception and organization, sensory-motor sequencing, automatization Verbal meaning, reasoning, word fluency, space, numerical ability, perceptual speed

Waber

1979

11

Neuropsychological battery

Dichotic listening, finger tapping, spatial ability, visual memory, right-left orientation, direction sense, word fluency, visuomotor coordination

Chen et al.

1981

20

WISC subtests, Bender Visual Motor Gestalt Test

Perceptual organization, tor functioning

Perceptual organization and freedom from distractibility significantly lower than verbal comprehension Perceptual organization and freedom from distractibility significantly lower than verbal comprehension Poorer performance on tests of spatial ability and serial processing Reasoning, space, numerical ability, and perceptual speed scores significantly below the normal level Poorer performance on word fluency, perception of left and right, visuomotor coordination, visual memory and motor learning than normal controls 16120 had space-form perceptual deficits; 13/20 had visual motor deficits

Author

From

“Cognitive

Psychosocial Adapted

Development Aspects

of Growth

in Turner Delay

Primary Mental Abilities Test U’SB)

Syndrome” (pp.

116-l

by H.-C. 17).

Steinhausen

Hillsdale,

and

NJ: Lawrence

1. Smith, Erlbaum

1986,

visuomo-

in 6. Stabler

Associates.

and

Copyright

L. Underwood 1986

by

(Eds.),

Lawrence

Slow Erlbaum

Grows

the Child:

Associates,

Inc.

by permission.

shown significant correlations between IQ and height. Researchersfrom Stanford University reviewed data from cycles II and III of the National Health Examination Survey conducted during the 1960s (Wilson, Duncan, Dornbusch, Ritter, & Rosenfeld, 1986). They found a clear association between height and IQ that did not appear to be related to socioeconomic status, race, relative physical maturity, or the presenceof disease (Figure 2). The reasons for this association are unclear. An unidentified variable such as a subtle intrauterine or postnatal insult may be involved, or the association may reflect the effects of different social interaction patterns and adult expectations based on height. Additional research is needed to examine this intriguing and unexpected finding more carehlly . n

6, Number

September-October

BEHAVIORAL AND EMOTIONAL

STATUS

Short stature does not directly cause behavioral and emotional problems. These problems stem from social factors such as the prejudice that exists in our

society with regard to height and the tendency to treat short children on the basis of their size rather than their age. Many clinicians have noticed that short children differ in their abilities to handle these social stresses,and researchersare attempting to describe and understand the behavioral and emotional correlates of short stature associated with various growth disorders. Self-Esteem and Social Competence

Early reports of uniformly lowered self-esteemand social withdrawal in short children (Rotnem, Genel, Hintz, & Cohen, 1977) have not been substantiatedby more recent studies. Lewis et al. (1986) reported that the short children they studied, ages 5 to 20, were viewed by peers as being as popular, attractive, and likable as their classmates.Young-Hyman (1986) studied 27 school-agedchildren being evaluatedfor growth delay (GHD, 12 children; CDG, 11 children; familial short stature, four children) and found that, although the children were unhappy about their appearance,they

Journal of Pediatric Health Care

Educational,

identified coping skills and strengths that contributed to high self-esteem.The children in this study were socially active and reported having close friends. Seventy-four percent of these children participated in one or more league sports. The older, more severely growth-delayed children perceivedthemselvesto be less physically and socially competent than did the younger, less delayed children. The parents, who were of above averagesocioeconomic status, tended to be psychologically healthy themselvesand optimistic for their children. Many parents had accurate perceptions of their children’s popularity, cognitive abilities, and socialcompetence. Parents who were short saw their children as more socially competent than did normal-statured parents. In this study, children with early onset short stature formed appropriate peer relationships early and were likely to maintain the samefriendships over time. These researchersconcluded that social competencewas not related to height alone, but rather to age of onset of growth delay, degree of short stature, and home environment. In the study by Richman et al. (1986) of children with CDG, teacher rating scalesdid not show a difference between the short children and controls with regard to social competence. Parents reported a pattern of internalizing behavior such as somatic complaints and social withdrawal in their children with CDG. The children with CDG rated themselvesas being unhappy and unpopular with peers, independent of their age and sex, and Rorschach test results pointed to a high level of introversion. Thesechildren did not exhibit more helplessness,hopelessness,or anxiety than did controls. The picture of the child with CDG that emergedfrom this study was one of a shy and dependent personality. Holmes et al. (1986) studied 47 short children (GHD, 17 children; CDG, 21 children; TS, 9 children) over a 3-year period. Participation in age-appropriate sports, hobbies, and household activities did not dil%er from reported norms; however, thesechildren exhibited a temporary, age-relateddecline in adjustment during early adolescence.According to parental ratings (based on the Child Behavior Problem Checklist), school and socialcompetencewere consistentwith ageexpectations at 9 years, declined between 12 and 14 years, and returned to normal by age 17. Younger short children in this study had more behavior problems than did the older children. The younger children exhibited both more internalizing behavior (such as withdrawal and somatic complaints) and more externalizing behavior (such as hyperactivity and aggressiveness;Figure 3). The older children exhibited a more normal, age-appropriate balanceof internalizing and externalizing behaviors.

Psychologic,

and Social Aspects of Short Stature

329

INT

Older

FIGURE 3 Short children’s social competence scores on the Child Behavior Problem Checklist. Mean J scores for younger and older subjects on the internalization (INT) behavior scale and externalizing (EXT) behavior scale. From “Longitudinal Evaluation of Behavior Patterns in Children with Short Stature” by C. S. Holmes, J. A. Karlsson, and R. G. Thompson, 1986, in B. Stabler and L. Underwood (Eds.), Slow Grows the Child: Psychosocial Aspects of Growth Delay (p. lo), Hillsdale, NJ: Lawrence Erlbaum Associates. Copyright 1986 by Lawrence Erlbaum Associates, Inc. Reprinted by permission.

n

Future Research

Some short children are able to adapt to their situation in healthy ways and accomplish appropriate developmental tasks, while others are impaired. Research is hampered by limited patient populations, controversial diagnostic criteria for some growth disorders, problems defining appropriate control groups, and difficulty assessingthe impact of stigmatization. Future research efforts should focus on further describing the social and behavioral differences among well-defined diagnostic groups of short children and their families, obtaining data on a broader cross-sectionof short children, assessingshort children longitudinally to discern specific, age-related changes in function, and assessing the effects of various medical and psychologic interventions. SUPPORT OF CHILDREN WITH SHORT STATURE

n

Parents,teachers,and other adults who come in contact with short children can have a positive impact on the quality of those children’s lives by supporting and encouraging the development of age-appropriate independence. Concerned adults should be aware of the educational, psychologic, and social problems that may exist for short children, be alert to warning signs of serious maladjustment, and be prepared to help these

330

Volume 6, Number 5, Part 2 September-October 1992

Rieser

Stigmatization . BOX 1 WARNtNG StCNS OF PSYCHOLOGIC PROBLEMS Increasing social isolation and withdrawal Avoidance of friends n Association with younger children n Selfdestructive or destructive behavior n Physical (somatic) complaints without cause n Consistently immature behavior n Poor adherence to medical treatment (if prescribed) n Low self-esteem n Abrupt drop in school grades n School truancy w Threats or discussion of suicide

n

n

children develop coping skills for dealing with a prejudiced and “big” world. Pediatric and school nursesand nurse practitioners can play an important role in educating parents, teachers,and school personnel about the special needs of short children and the warning signs of serious adjustment problems (Box 1). More information about management and guidance issuespertinent to short children can be found in Meyer-Bahlburg (1985, 1990) and in the written material listed in Box 2. juvenilization

The tendency to treat short children as if they were younger than they are (juvenilization) is common; a lo-year-old who looks as if he is 6 years old is likely to be treated like a 6-year-old. Adults tend to overprotect and “baby” short children; they expect and demand less from short children than from age-mates. Children may respond to this treatment by evading the pressure and demands of age-appropriatedevelopment and behaving in a manner that reflects their size rather than their age. This contributes to social withdrawal, dependenceon parents, and lack of assertiveness, all of which interfere with healthy development. Clothing is an important aspect of appearance,and short children should dress in clothes that are stylish and appropriate for age, even if that means learning to sew or having clothes made. The discrepancy between the child’s age and size should be m inimized as much as possible (clothing, makeup, hairstyle). The tendency to juvenilize short children should be pointed out to parents and other involved adults so that they can monitor their behavior and develop and maintain age-appropriate expectations for short children. Pediatric nurse practitioners, with their knowledge of normal childhood development, can serve as valuable resourcesin this regard.

Individuals who deal with short children must develop increased sensitivity to the manifestations of our prejudice with regard to height. The extent to which we value tall stature is reflected in our language (poor judgment is being “shortsighted,” being cheated is “getting the short end of the stick”), in the amount of personal spacewe afford each other, and in the assumptionswe make about personalcharacteristicsbasedon height. We prize tall stature and associateit with wealth, success, and other positive attributes. Many of the problems that short children (and adults) face result from the stigmatization they experience.Changing these prejudicial attitudes about height should be an important goal for everyone. One way to approach this is to be alert for hidden value judgments in our language; avoid being “shortsighted” and gently remind others that the words we use reflect the assumptions we make. Another approach is to identify positive role models who are short individuals, some of them famous, who have succeeded in accomplishing their personal goals. Counseling Parents and Teachers

The physical environment presents challengesto short children, and nurses can assist parents and teachers in identifying obstaclesand devising remedies.Chairs may leave short legs unsupported; water fountains may be too high, and emergency exit doors may be too heavy to open without assistance;closet rods may be too high, and kitchen cupboards cannot be reached. The child should be involved both in identifying problems and in solving them. The goal in modifying the physical environment is the same as for other psychosocialinterventions for short children-encouraging the development of age-appropriate skills and independence. Social discomfort prompts some short children to develop a pattern of avoiding strangers and lim iting interactions outside of the home. Although this responsemay seemeasierthan dealing with the problems that arise, it interferes with normal development. Assertivenesstraining has been useful for many short children and adults in overcoming the obstaclesthey confront in daily life. Short children and their family members should be encouragedto develop a routine response to curious questions and remarks, such as, ‘Yes, I really am 14. I’m just short for my age.” Having the child practice different responsesat home to social situations (role playing) often is useful in increasing the child’s confidence-“Hi. You can’t seeme becauseof this high counter, but I’m next in line.” Teasing is a universal problem for short children, and they differ considerablyin their ability to handle it. “Just ignore it” is not a useful response in most situations because it does not acknowledge the validity of the

Journal of Pediatric Health Care

Educational, Psychologic, and Social Aspects of Short Stature

n BOX 2

WRllTEN

MATERlAL K)R CHILDREN AND FAMILIES

Phifer, Kate. (1979). Crowing up small: a handbook for short people. Middlebury, VT: Paul Eriksson Publisher. “How parents and others can help children understand it, cope with it, take advantage of it, and maybe even cure it.” Phifer, Kate. (1987). Tall and small: a book about height. New York: Walker & Co. Contains suggestions for dealing with height-related school and peer problems; aimed at junior high and high school aged young people. Rieser, Patricia, & Meyer-Bahlburg, Heino F. L. (1991). Short & OK: a guide for parents of short children. Available from: The Human Growth Foundation, P.O. Box 3090, Falls Church, VA 22043. Provides parents with concrete, specific information to help them support a short child’s normal development and deal constructively with the stresses associated with short stature. Webster-Doyle, Terence. (1991). Why is everybody always picking on me! A guide to handling bullies. Middfebury, VT: Atrium Publications. Contains stories, activities, and practical suggestions for young people who are faced with problems involving conflict. SUPPORT ORGANfZATlONS Human Growth Foundation is a nonprofit national organization made up of families affected by short stature and other individuals who are interested in growth problems. Its goals include support of research into normal and abnormal growth, family education and support, public education, and education of health professionals. National Office: P.O. Box 3090, 7777 Leesburg Pike, Suite 2028, Falls Church, VA 22043; (800) 451-6434.

child’s feelings. Guided exploration of the teasing with the child (When and where does it happen?Who starts it? Exactly what is said or done?) provides the adult with a gauge of the severity of the problem and lays the groundwork for problem solving. Walking away from the situation may be effective, but children should be encouragedto develop a set of ready responsesto use when teasing occurs: “I have a medical condition, and it hurts my feelings when you say that;” “My body is small, but my brain is just as big as yours-maybe bigger.” Role playing and rehearsalare useful tools in dealing with teasing, as is a good senseof humor. Several of the books listed in Box 2 contain concrete

331

RESOURCES Turner Syndrome Society is comprised of women and girls with TS and their families. Its goals include fostering research; providing parent, public, and medical education; and improving the quality of life of affected individuals throughout their life span. National Office: 768214 Twelve Oaks Center, 15500 Wayzata Blvd., Wayzata, MN 55391; (612) 475-9944. Turner Syndrome Society of Canada serves TS individuals in that country. National Office: 7777 Keele St., Floor 2, Concord, Ontario, Canada L4K XYF. Short Stature Foundation operates a toll-free helpline with information about services available to short people and publishes a catalog of adaptive devices for people with growth and skeletal disorders. Its goal is to provide services, information, and advocacy to ensure the wellbeing and independence of short people. National Office: P.O. Box 5356, Huntington Beach, CA 92615; Helpiine (800) 24-DWARF. The Major Aspects of Growth in Children Foundation (MAGIC) is dedicated to the understanding of growth and overall development of children. Support groups are located across the United States. The Foundation offers booklets for parents, a pen pal list, and a children’s newsletter. National office: 1327 North Harlem Ave., Oak Park, IL 60302; (800) 3-MAGIC-3. Little People of America (LPA) is made up of adults with severe short stature. Average sized parents may join the Parents Auxiliary. LPA provides a social outlet for people facing the problems of severe short stature; it is also a valuable resource for people struggling to overcome stature-related problems in daily life and employment. National Office: P.O. Box 9897, Washington, DC 20016.

suggestions for helping children handle teasing and bullying. Parents of short children should be counseledto acknowledge the validity and importance of the children’s feelings by encouraging them to discuss troublesome issues,problems, and feelings. If verbal expressionis difficult for a child, storytelling, drawing, or doll play may provide insight into what the child is experiencing. Books, movies, and television shows can serveasspringboardsfor discussionof personalissues.Problem solving often involves stepping back from the problem, seeing it from a different perspective, and breaking it into smaller,more manageablepieces.Short children need to

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be encouraged to take responsibility for solving their own problems, with parental support and guidance; this will foster their sense of confidence and self-reliance. School is a major social arena in childhood. Parents of short children may need to have regular contact with teachers and counselors. Short children with conditions that put them at risk for learning disabilities (GHD and TS, for example) should undergo a complete psychoeducational evaluation at the time of diagnosis or when they enter school. Teachers and coaches should be cautioned to maintain age-appropriate expectations for short children and to refrain from making them “teacher’s pets.” Parents and teachers can work together to help short children identify and develop strengths, skills, interests, and inner resources (courage, humor, persistence, flexibility) that are unrelated to height. Physical education teachers and coaches should be counseled to encourage short children to participate in whatever sports they enjoy. In some locations, schools have sponsored separate teams for shorter children to give them an opportunity to compete and develop skills. Many sports exist in which size is not a major factor: swimming, gymnastics, golf, ice hockey, soccer, karate, skateboarding, cycling, and wrestling. As with hobbies and other extracurricular activities, short children should be encouraged to explore the range of possibilities, find what they enjoy, and do their best. n

CONCLUSION

Children with short stature may experience academic, psychologic, and social problems. Awareness of current research findings and supportive interventions will enable nurses to provide information, guidance, and support for short children and their families. Early identification of learning impairments, maladaptive behavior patterns, and social stressors permits prompt intervention, resulting in improved quality of life for affected children. n REFERENCES Holmes, C. S., Hayford, J. T., & Thompson, R. G. (1982). Parents and teachers’ differing views of short children’s behavior. Child: Care, Health and Development, 8, 327-336. Holmes, C. S., Karlsson, J. A., & Thompson, R. G. (1986). Longitudinal evaluation of behavior patterns in children with short stature. In B. Stabler & L. Underwood (Eds.). Slowgrurrs thechild: Psycbosociulqects of5rowtb delay (pp. 1-12). H&dale, NJ: Lawrence Erlbaum Associates. Holmes, C. S., Thompson, R. G., & Hayford, J. T. (1984). Factors related to grade retention in childen with short stature. Child: Care, Health and Deve&pment, 10, 199-210.

6, Number

September-October

5, Part 2 1992

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