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: [6]
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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) [7]
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)
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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 [8]
Substance abuse
Absent spouse or father of child
Myriad of other child abuse–associated issues involving poverty, poor education, generational abuse, and neglect
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Abnormal endocrine function is present but normalizes when the child is removed from the unsafe and nonnurturing environment. [9]
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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.
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Diagnosis of PSS is confirmed by the removal of the child from the unsafe or nonnurturing environment and observation of the following with time: [2]
Demonstration of catch-up growth
Improvements in behaviors
Normalization of hormonal disturbances
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. [10] 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.
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Lung and cardiac examinations are important in excluding organic causes of growth failure, such as cystic fibrosis or heart defects.
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Protuberant abdomen and hepatomegaly, which often are found in children who are malnourished, can be observed in individuals with PSS.
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Perform skin examination for signs of past or chronic abuse (eg, scars, burns, pattern injury) and signs of nutritional or vitamin deficiency.
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Perform examination of genitals and anus for evidence of past or chronic sexual abuse in any patient with child abuse or neglect.
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A neurologic examination to exclude organic causes of bizarre behaviors is usually performed.
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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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.
