The retrospective study examined the medical records of 407 patients with strabismus (misaligned eyes) and compared them with records of children matched for age and sex but with normal eye alignment. Children with eyes that diverged (exotropia) were three times more likely to develop a psychiatric disorder than were the control subjects, while those with inward deviating eyes (esotropia) showed no increase in the incidence of mental illnesses.

Brian Mohney, M.D., the Mayo Clinic pediatric ophthalmologist who led the study, says the results can help alert physicians to potential problems in their pediatric patients. “Pediatricians and family practice physicians who see children with strabismus should be aware of the increased risk of mental illness,” says Dr. Mohney. “They can hopefully be alert to the earliest signs of psychiatric problems in patients with exotropia, so they can consider having them seen by a psychologist or psychiatrist.”

Strabismus is a misalignment of the eyes that affects three to five percent of children, and about 125,000 new cases are diagnosed each year in the United States.

“Intermittent exotropia occurs in approximately 1 percent of developmentally healthy children in the United States and, given its predominance over esodeviations [when the eye turns in] among Asian populations, it may be the most prevalent form of strabismus worldwide,” the authors write as background information in the article.

Jeff A. McKenzie, B.A., and colleagues at Mayo Clinic, Rochester, Minn., analyzed the medical records of 183 children younger than 19 in Olmsted County, Minn., who were diagnosed with intermittent exotropia between 1975 and 1994. For each patient, the researchers identified one control child who was the same age but did not have a diagnosis of any type of strabismus. Both groups were followed to an average age of 22.

During the 20-year study period, 97 of the children with intermittent exotropia (53 percent) were diagnosed with a mental health disorder, compared with 55 controls (30.1 percent)—meaning that patients with the condition had an increased risk of developing a psychiatric illness. Mental health disorders were diagnosed in 63 percent of boys (41 of 65) and 47 percent of girls (56 of 118) with intermittent exotropia, compared with 33 percent of boys (22 of 66) and 28 percent of girls (33 of 117) in the control group.

“Additionally, males with intermittent exotropia had a greater use of psychotropic medication, psychiatric emergency department visits, psychiatric hospital admissions, suicide attempts and suicidal ideation than controls, and females with intermittent exotropia had more suicidal ideation than controls,” the authors write.

The reasons underlying these associations remain unclear, the authors note. “Studies regarding the psychosocial impact of strabismus have reported that individuals with intermittent exotropia are not judged more poorly than individuals with orthotropia [the absence of strabismus] by adult observers. However, a negative bias toward people with strabismus has been demonstrated in children,” the authors write. “Although this study focused on mental illness that was diagnosed by early adulthood, there is also evidence to suggest that the social problems associated with strabismus persist and even intensify into adult life.”

“Further study is needed to determine whether interventions for intermittent exotropia can decrease or otherwise alter the future development of mental illness,” they conclude.

This study was supported in part by an unrestricted grant from Research to Prevent Blindness Inc., New York, New York.

Journal reference:

1. Jeff A. McKenzie; Jason A. Capo; Kevin J. Nusz; Nancy N. Diehl; Brian G. Mohney. Prevalence and Sex Differences of Psychiatric Disorders in Young Adults Who Had Intermittent Exotropia as Children. Archives of Ophthalmology, 2009; 127 (6): 743 DOI: 10.1001/archophthalmol.2009.68

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ARTICLE

Short Stature in a Population-Based Cohort: Social, Emotional, and Behavioral Functioning

Joyce M. Lee, MD, MPH^a, Danielle Appugliese, MPH^b, Sharon M. Coleman, MS, MPH^b, Niko Kaciroti, PhD^c, Robert F. Corwyn, PhD^d, Robert H. Bradley, PhD^e, David E. Sandberg, PhD^f and Julie C. Lumeng, MD^c,f

^a Pediatric Endocrinology, Child Health Evaluation and Research Unit
^c Center for Human Growth and Development
^f Child Behavioral Health, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
^b Data Coordinating Center, School of Public Health, Boston University, Boston, Massachusetts
^d Department of Psychology
^e Family and Human Dynamics Research Institute, Arizona State University, Tempe, Arizona

ABSTRACT

OBJECTIVE: The goal was to determine whether there were significant differences between children of normative versus short stature in behavioral functioning and peer relationships, according to teacher and child reports.

METHODS: The study included 712 boys and girls in the sixth grade, from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Main outcome measures included Achenbach Teacher’s Report Form internalizing, externalizing, and total scores; Children’s Depression Inventory scores (child report); Life Orientation Test-Revised scores (child report); Child Behavior with Peers questionnaire asocial with peers, excluded by peers, and peer victimization subscale scores (teacher report); peer social support and victimization scores (child report); and relationships with peers score (teacher report). In bivariate comparisons, these outcomes were compared for children of relatively short (height of <10th percentile) versus nonshort (height of 10th percentile) stature, and effect sizes were calculated. Multivariate linear regression models adjusted for maternal education, income/needs ratio, race, and gender.

RESULTS: Effect sizes ranged from 0.00 to 0.35. Short children reported marginally higher levels of self-perceived peer victimization, compared with their nonshort peers. There were no significant differences in the rest of the outcomes for children of short versus nonshort stature, in either unadjusted or adjusted models.

CONCLUSION: Although short children from a population-based sample reported marginally higher levels of self-perceived peer victimization, they did not differ from their nonshort peers in a range of social, emotional, and behavioral outcomes.

Key Words: short stature • quality of life • child

Abbreviations: GH—growth hormone • TRF—Teacher’s Report Form • ITN—income/needs

Monitoring of linear growth during childhood represents one of the most important tasks for pediatric providers, with the American Academy of Pediatrics recommending measurement of a child’s height and weight 20 times from birth through middle childhood.¹ Children with growth that falls outside the normative values for stature, particularly children with short stature, defined as a height ranging from <3rd percentile to <10th percentile,² raise concerns for both pediatric providers and parents. When the child is healthy, parental concern about height often is rooted in the perception that shorter children experience more problems in social, emotional, and behavioral functioning. However, parents may be misattributing these difficulties to short stature when actually they are related to other stressors.³

Previous studies reported that short children have higher rates of behavioral difficulties and lower social competency, compared with children of normal stature.^4–6 However, interpretation of those studies was limited by several factors. Some studies included children with growth hormone (GH) deficiency or other syndromes, which made it unclear whether the underlying pathologic condition or short stature are responsible for the difficulties in psychosocial adjustment.^5–7 Other studies lacked details regarding subject recruitment and subject nonresponse rates,^4,7 which led to uncertainty regarding the representativeness of the samples.⁸ More recent studies have suggested that short children have normal psychosocial adjustment and the behavioral or social difficulties identified might have been attributed inappropriately to the short stature.^9–11 Behavioral and peer-relationship ratings from most studies were mostly self- or parent- reported^10–12 or were based on populations from a single medical center.^5,10,11 Finally, previous studies included cohorts of children with heights of <3rd percentile. Pediatric providers, however, are confronted more commonly with families concerned about their children with less-extreme short stature (eg, height of <10th percentile), a population that is seeking evaluation for short stature in the pediatric specialty clinic setting^13,14 but for which there are relatively few data regarding potential differences in behavioral and social functioning.

We are unaware of studies that have evaluated the relationship between psychosocial adaptation and stature among children of diverse socioeconomic status drawn from a variety of geographic areas. Furthermore, few studies have used both teacher reports and child reports. We sought to test the hypothesis that there would be no significant differences in social, emotional, and behavioral functioning between children of short stature (defined as <10th percentile) and those of nonshort stature in a recent, large, population-based cohort of children of diverse socioeconomic status drawn from 10 geographic regions in the United States.

REFERENCES :

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2. Agency for Healthcare Research and Quality. Criteria for Determining Disability in Infants and Children: Short Stature. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Evidence Report/Technology Assessment 73, AHRQ Publication 03-E025
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13. Cuttler L, Silvers JB. Growth hormone treatment for idiopathic short stature: implications for practice and policy. Arch Pediatr Adolesc Med. 2004;158 (2):108 –110[Free Full Text]
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16. National Institute of Child Health and Human Development. NICHD Study of Early Child Care and Youth Development: Phase 3 Data Manuals. Available at: http://secc.rti.org/manuals.cfm?P=3. Accessed January 12, 2006
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18. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and development. Vital Health Stat 11. 2002;(246):1 –190
19. Achenbach T. Manual for the Teacher’s Report Form and 1991 Profile. Burlington, VT: University of Vermont; 1991
20. Achenbach TM, Rescorla LA. Manual for the ASEBA School-Age Forms and Profiles. Burlington, VT: University of Vermont; 2001
21. Kovacs M. Children’s Depression Inventory. North Tonawanda, NY: Multi-Health Systems; 1992
22. Scheier MF, Carver CS, Bridges MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test. J Pers Soc Psychol. 1994;67 (6):1063 –1078[CrossRef][Web of Science][Medline]
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27. Kochenderfer BJ, Ladd GW. Victimized children’s responses to peers’ aggression: behaviors associated with reduced versus continued victimization. Dev Psychopathol. 1997;9 (1):59 –73[CrossRef][Web of Science][Medline]
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31. Ladd GW. Social networks of popular, average, and rejected children in school settings. Merrill-Palmer Q. 1983;29 (3):283 –307
32. Grimberg A, Kutikov JK, Cucchiara AJ. Sex differences in patients referred for evaluation of poor growth. J Pediatr. 2005;146 (2):212 –216[CrossRef][Web of Science][Medline]
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34. 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 1):67 –72[Web of Science][Medline]
35. Voss LD, Mulligan J. Bullying in school: are short pupils at risk? Questionnaire study in a cohort. BMJ. 2000;320 (7235):612 –613[Free Full Text]
36. Warm TR. The role of teasing in development and vice versa. J Dev Behav Pediatr. 1997;18 (2):97 –101[CrossRef][Web of Science][Medline]
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38. Spencer TJ, Biederman J, Harding M, O’Donnell D, Faraone SV, Wilens TE. Growth deficits in ADHD children revisited: evidence for disorder-associated growth delays? J Am Acad Child Adolesc Psychiatry. 1996;35 (11):1460 –1469[CrossRef][Web of Science][Medline]
39. Spencer TJ, Biederman J, Harding M, O’Donnell D, Faraone SV, Wilens T. Growth deficits in children with attention deficit hyperactivity disorder. Pediatrics. 1998;102 (2 suppl):501 –506[Abstract/Free Full Text]
40. Doull IJ, Freezer NJ, Holgate ST. Growth of prepubertal children with mild asthma treated with inhaled beclomethasone dipropionate. Am J Respir Crit Care Med. 1995;151 (6):1715 –1719[Abstract]
41. Sharek PJ, Bergman DA. The effect of inhaled steroids on the linear growth of children with asthma: a meta-analysis. Pediatrics. 2000;106 (1). Available at: www.pediatrics.org/cgi/content/full/106/1/e8
42. US Food and Drug Administration. FDA approves Humatrope for short stature. Previously available at: www.fda.gov/bbs/topics/ANSWERS/2003/ANS01242.html. Accessed July 7, 2004

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Supported  by
CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646 

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.

Supported  by
CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646 

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO 

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved

Supported  by
CLINICAL PEDIATRIC ONLINE

Yudhasmara Foundation

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.