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This is to certify that the

dissertation entitled

Family Factors in the Psychosocial Adaptation
of Children and Adolescents with Short Stature

presented by

Carol Cracchiolo Laub

has been accepted towards fulfillment
of the requirements for

Ph.D. mgmem Psychology

 

 

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MSU le An Affirmative Maud Opportunity lnetltuion
WINS-a1

FAMILY FACTORS IN THE PSYCHOSOCIAL ADAPTATION OF CHILDREN
AND ADOLESCENTS WITH SHORT STATURE

By

Carol Cracchiolo Laub

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1995

ABSTRACT

FAMILY FACTORS IN THE PSYCHOSOCIAL ADAPTATION OF CHILDREN
AND ADOLESCENTS WITH SHORT STATURE

By

Carol Cracchiolo Laub

Children significantly below average in height are at risk for poorer
psychosocial outcomes than children of normal height. However, recent
investigations have yielded inconsistent results regarding the functioning of children
with short stature (SS). The present study utilized both questionnaire and interview
data to assess the psychosocial adjustment of children with SS (at or below the 5th
percentile of height for age). Relationships between the family environment,
children’s and parents’ self-worth, experiences related to stature, coping strategies,
and child outcomes were also examined. Subjects were 33 children with SS and their
parent(s), and a matched comparison group of 33 healthy children of normal stature
(NS) and their parent(s).

Compared to children with NS, children with SS were rated by their parents as
having more behavior problems and lower social competence. Children with SS rated
themselves as having lower global self-worth and athletic competence, and as less
satisfied with their physical appearance than children with NS. Girls and boys with
SS had similar levels of behavior and social problems. However, girls with SS
participated in fewer extracurricular activities, and rated themselves as less athletically
competent and less satisfied with their physical appearance than boys with SS and

children with NS. Younger children with SS reported higher levels of self-

competence and global self-worth than older children with SS, but there were no age
differences in parent-reported behavior problems or competence. Devaluing physical
appearance was related to greater self-competence and higher global self-worth in
children with SS.

The family environments of children with SS did not differ significantly from
those of children with NS, although families of children with SS described themselves
as somewhat less supportive. Family support was associated with better child
adjustment, whereas family control and conflict were associated with poorer child
outcomes. Fathers’ coping, global self-worth, and the impact of their own stature
were more strongly related to child outcomes than mothers’. A model of stress and
coping with SS predicted 46% of the variance in child behavior problems.
Methodological considerations in the assessment of coping and implications for

clinical interventions are discussed.

To Rick and Emily, my greatest inspirations.

iv

ACKNOWLEDGNIENTS

I would like to extend my deepest gratitude to the Chairpersons of my
dissertation committee, John McKinney and Elizabeth Seagull, for their enduring
support, guidance, and confidence in me. I would also like to thank the members of
my dissertation committee, Hiram Fitzgerald, Robert Caldwell, and Bruce Wilson, for
their willingness to contribute to the development and completion of this work. Bruce
Wilson and Kathleen Seitz deserve special recognition for conceptualizing the original
seeds for this research and allowing me to cultivate them into my own.

I would also like to thank my family and friends, who supported me
throughout this project with their love, encouragement, confidence, and assistance.
Most of all, I want to express my appreciation to my husband, Rick, for all he has

done in order to make this possible.

TABLE OF CONTENTS

Page

LIST OF TABLES ...................................... viii
LIST OF FIGURES ....................................... x
CHAPTER 1 - Review of the Literature .......................... 1
Introduction ...................................... 1

Social Stigma and Stature Stereotypes ...................... 6
Self-Image, Self-Esteem, and Self-Competence ................ 10
Juvenilization: Living up to Expectations? ............... 12

Psychosocial Adjustment to SS ........................... 16
Psychosocial Outcomes in Childhood and Adolescence ........ 16

Psychosocial Outcomes in Adulthood .................. 26

Family Factors and Child Adjustment to SS .............. 28

Transactional Stress and Coping Model ..................... 36
Limitations of Previous Research on SS ..................... 40
Overview and Research Question ......................... 42
CHAPTER 2 - Research Hypotheses ........................... 44
CHAPTER 3 - Method .................................... 46
Subjects ......................................... 46
Procedures ....................................... 49
Measures ........................................ 52
Demographic Parameters/Instrumental Family Resources ...... 52

Family Mediational Processes ....................... 53

Child Mediational Processes ........................ 56

Child Adjustment .............................. 58
Semi-Structured Interview ......................... 60

CHAPTER 4 - Results .................................... 64
Hypotheses 1 and 2: Group Differences ..................... 65
Hypothesis 3: Gender Differences ......................... 68
Hypothesis 4: Age Differences .......................... 73

vi

Page

Hypothesis 5: Family History of SS ....................... 74
Hypothesis 6: Devaluing Physical Appearance ................. 75
Hypotheses 7, 8, 9, and 10 : Family Factors in Child Outcomes ..... 77
Hypothesis 11: The Stress and Coping Model ................ 82
CHAPTER 5 - Discussion .................................. 97
Group Differences .................................. 97
Gender Differences .................................. 100
Age Differences .................................... 101
The Impact of a Family History of SS ...................... 103
The Importance of Physical Appearance ..................... 105
Family Factors in Child Outcomes ........................ 106
Coping ......................................... 110
The Stress and Coping Model ........................... 113
Study Limitations and Future Directions ..................... 117
APPENDICES
A. Frequently Used Acronyms ......................... 122
B. Recruitment Letter to Parents ........................ 123
C. UCRIHS Letters of Approval ........................ 124
D. Informed Consent Form ........................... 126
E. Questionnaire Packet Letter ......................... 127
F. Child and Family Information Questionnaire ............... 128
G. Semi-Structured Interview for Parents ................... 131
H. Semi-Structured Interview for Children and Adolescents ....... 134
I. Coping Coding Manual ............................ 137
J. Sample Coding Sheet ............................. 140
LIST OF REFERENCES .................................. 141

vii

Table

10

11

LIST OF TABLES

Page
Group Comparisons for the Child Behavior Checklist .............. 66
Group Comparisons for the Self-Perception Profile ............... 67
One-Way Analysis of Variance (AN OVA) for Stature X
Gender Groups and CBCL Behavior Problem Scales .............. 70
One-Way Analysis of Variance (AN OVA) for Stature X
Gender Groups and CBCL Competence Scales .................. 71
One-Way Analysis of Variance (AN OVA) for Stature X
Gender Groups and Self-Perception Scales .................... 72
Pearson Correlations Between the Family Environment
Factors and Child Outcome Measures ....................... 79
Pearson Correlation Coefficients for the Diagnostic/
Demographic and Child Adjustment Variables of the
Stress and Coping Model ............................... 83
Pearson Correlation Coefficients for the Family
Mediational and Child Adjustment Variables of
the Stress and Coping Model ............................. 84
Pearson Correlation Coefficients for the Child
Mediational and Child Adjustment Variables of
the Stress and Coping Model ............................. 85
Summary of the Multiple Hiearchical Regression
Scores for Total Behavior Problems ........................ 89

Summary of the Multiple Hiearchical Regression
Scores for Social Competence ............................ 90

viii

Table Page

12 Summary of the Multiple Hiearchical Regression
Scores for Total Behavior Problems: Coping
Removed from the Model ............................... 94

13 Summary of the Multiple Hiearchical Regression
Scores for Academic Competence: Coping
Removed from the Model ............................... 95

14 Summary of the Multiple Hiearchical Regression
Scores for Social Competence: Coping
Removed from the Model ............................... 96

ix

LIST OF FIGURES

Page
Stress and Coping Model for Short Stature .............. 39
Variables and Measures .......................... 63

CHAPTER 1
Review of the Literature

Introduction

The recent increase in the availability of synthetic human growth hormone has
led to growing interest in the psychosocial and cognitive functioning of individuals
with short stature (SS). Factors related to the expense and possible negative side-
effects of treatment with synthetic human growth hormone (GH), make it especially
important to clarify the nature and degree of psychosocial benefits of such treatment,
particularly for individuals who are not growth hormone deficient, but may respond to
such treatment nevertheless (see Appendix A for frequently used acronyms).

Short stature is the most frequent reason for referral to pediatric endocrinology
clinics and is a "physiological manifestation of growth failure which results from a
variety of causes" (Finley, Crouthamel, & Richman, 1982, p. 27). Rieser and
Underwood (1990) divide the causes of growth failure and short stature into three
broad categories: 1) intrinsic defects of the growing tissues (skeletal dysplasias,
autosomal abnormalities, abnormalities of the X chromosome [c.g. , Turner
Syndrome], and dysmorphic or primordial dwarfism [c.g. , abnormalities resulting
from in utero insults or genetic defects]); 2) abnormalities in the environment of
growing tissues (nutritional insufficiency, renal disease, cardiac disease,
gastrointestinal disease, poorly controlled diabetes, and vitamin D resistant rickets or
other metabolic problems); and 3) endocrine abnormalities (thyroid deficiency, growth

hormone deficiency, and glucocorticoid excess [c.g. , adrenal tumors]). Growth

2

hormone deficiency (GHD) is one of the most widely studied growth disorders and is
caused by a deficiency of growth hormone secretion secondary to pituitary gland
malfunction or hypothalamic dysfunction. When growth hormone is the only
hormone not secreted by the pituitary, the disorder is labeled isolated growth hormone
deficiency (IGHD). When more than one of the pituitary hormones are deficient, the
disorder is labeled multiple hormone deficiency (MHD) (Siegel, 1990). In many
cases, the etiology of the growth hormone deficiency is unexplained or idiopathic
(Siegel, 1990). Constitutional delay (CD) is a condition in which the cause for
growth delay is unknown. Children with CD have normal birth weight, early growth
failure, subsequent normal growth velocity, height below the 5th percentile in
childhood and delayed pubertal onset, but the potential to attain normal adult height
(Siegel, 1990). By contrast, familial short stature (FSS) is a condition in which the
rate of growth is normal, the bone age is within 2 SD of that expected for age, and
significant short stature is associated with genetic inheritance.

Regardless of its etiology, short stature has long been regarded as a social
handicap which carries with it a significant degree of stigmatization, especially for
very short males (Martel & Biller, 1987). In the context of a "heightist" society,
short adults face discrimination in being hired for a job, starting salaries, and salary
increases (Gillis, 1982). While the stigmatization and juvenilization of short
individuals begins in early childhood, these social processes continue throughout
adolescence and adulthood (Clopper, MacGillivray, Mazur, Voorhess, & Mills, 1986;

Eisenberg, Roth, Bryniarski, & Murray, 1984; Martel & Biller, 1987). Constant

3

exposure to stigmatization and juvenilization is likely to shape the developing self-
concepts, personalities, and motivations of short individuals.

Studies of children with short stature (SS) suggest that compared to children of
normal height, children with SS are more psychosocially immature and withdrawn
(Gordon, Crouthamel, Post, & Richman, 1982), have more somatic complaints and
less tolerance for frustration (Drotar, Owens, & Gotthold, 1980; Gordon et al.,
1982), poorer academic achievement (Siegel, 1990), and experience greater
juvenilization in social interactions and overprotection by their parents (Martel &
Biller, 1987; Rotnem, Genel, Hintz, & Cohen, 1977). However, there is significant
inconsistency in the literature regarding developmental outcomes, and gender, age,
and etiological differences among children with SS. Many of these inconsistencies
can be attributed in part to methodological flaws. For example, the majority of
studies in this field: 1) examine heterogeneous groups of children with SS; 2) rely
solely on questionnaire measures from either the parents or children; 3) fail to
account for the effects of socioeconomic status; 4) fail to examine family factors
affecting the child’s adaptation to SS; and 5) do not provide a group of carefully
matched control subjects for comparison.

While earlier investigations of children and adolescents with SS indicate that
they have significant psychosocial, behavioral, and cognitive deficits (e.g. , Abbott et
al., 1982; Gordon et al., 1982; Holmes et al., 1982; Rotnem et al., 1977), more
recent studies demonstrate average or elevated global self-esteem in children with SS

(Young-Hyman, 1986; 1990). Despite positive global self-esteem, however, specific

4

deficits in cognitive and social functioning have been identified (Siegel, 1990). In
addition, of note is the fact that non-clinic populations of children with SS do not
demonstrate significantly more psychosocial or behavioral problems than age-matched
control children of normal height (Voss, Bailey, Mulligan, Wilkin, & Betts, 1991).
The non-clinic children with SS do, however, demonstrate some tendency toward poor
concentration and hyperactivity. Differences between clinic-referred and non-clinic
populations of children with SS suggest that there is more significant concern about
the psychosocial adjustment of those children referred for treatment for SS in either
the referring physician, other significant adults (e. g. , parents, teachers, grandparents),
or the child him- or herself.

While it is likely that children who are referred for treatment for SS do indeed
manifest greater psychosocial and behavioral distress, very little attention is given to
the factors contributing to their difficulties, and who is most concerned about their
growth failure (e.g. , parents, physicians, children). In contrast to the significant
efforts which have been made to treat SS with GH, very little work has focused on
psychosocial evaluation and intervention with this population. Although treatment
with GH is promising, data on adults who were treated with GH as children or
adolescents is somewhat equivocal. Many children and parents have unrealistic
expectations of treatment with GH and are unhappy with the results (Clopper, 1992;
Grew, Stabler, Williams, & Underwood, 1983; Rotnem et al., 1980). Furthermore,
in spite of height augmentation, many GHD adults continue to be socially withdrawn,

have lower rates of marriage and employment, and experience psychosocial distress

5
(Clopper et al., 1986; Dean et al., 1986; Mitchell et al., 1986).

As advances are made in the medical treatment of SS, there is a clear need to
increase our efforts to understand better the psychosocial issues which confront
children with SS throughout their development into adulthood. In order to treat the
patient with SS with a more biopsychosocial approach, it would be valuable to
identify which children are at risk for poor psychosocial adaptation to SS. In
addition, it would be useful to clarify the ways in which family factors contribute to
the developmental outcomes of children with SS.

This study combined questionnaire and interview data to examine relationships
between the family environment, children’s and parents’ experiences related to height,
coping styles, and child psychosocial outcomes. In addition, the present study tested
the application of a stress and coping model which links the child’s diagnosis, family
instrumental resources, family emotional resources and mediational processes, and

child mediational processes, to child psychosocial outcomes.

Social Stigm and Stature Stereotypes

In their comprehensive review of social stigma and self-esteem, Crocker and
Major (1989) define stigmatized social groups as " social categories about which others
hold negative attitudes, stereotypes, and beliefs, or which, on average, receive
disproportionately poor interpersonal or economic outcomes relative to members of
society at large because of discrimination against members of the social category" (p.
609). Stigma theory holds that social disapproval, the hallmark of stigmatization,
leads to an individual’s belief that a certain attribute is undesirable to possess. The
degree of stigmatization that is assigned to a characteristic is largely determined by its
severity, concealability, and disruptfulness. In an attempt to normalize the
stigmatizing condition, affected individuals attempt to conceal it and suffer from
diminished self-esteem (Westbrook, Bauman, & Shinnar, 1992), which impacts their
overall satisfaction with life (Diener, 1984).

The degree to which individuals are negatively impacted by social stigma is
largely dependent on their ability to cope effectively with the everyday stressors
associated with feeling different from what is considered to be "average" or desirable.
Ainlay, Coleman, and Becker (1986) propose that stigma must be viewed within a
developmental perspective, which takes into account continuities and discontinuities
throughout the lifespan as the impact of stigma on personal development waxes and
wanes. They state that " even when stigmas no longer continually tug at the individual
in daily routines, they linger as memories, reflections of culture that alter people’s

behavior and their lives" (p. 7). These writers acknowledge the paradoxical nature

7

of stigma, in that it can be both "dehumanizing and inspiring." The degree to which
one overcomes the negative impact of stigma is dependent on numerous factors
including: individual personality, physical environment, emotional and material
resources, cultural beliefs, education, and social status. Through the process of

" normalization" the stigmatized individual adapts to society by reducing the amount of
deviation from cultural norms, and by decreasing the emphasis on the stigmatizing
condition (Becker & Arnold, 1986).

Given that stature is one of the most readily apparent characteristics of an
individual, extreme short stature is a stigmatizing feature which is not easily
concealed from social interactions and reactions. Within the context of a "heightist"
culture, short stature can be considered a social handicap, which shapes interpersonal
relationships, the development of self-image and self-competence, coping styles,
personality, and motivations. In one of the earlier works concerning stature, Gerling
(1939) recognized that society’s view of height is "often out of proportion to its real
value" (p.15) . However, he dedicated the majority of his text to techniques of
increasing one’s apparent stature through posture, physical exercise, dress, and
"stature aids, " thus promoting rather than combating the root of the problem--
"heightism. "

Society’s value of height is clearly demonstrated in the stereotypes attributed to
persons of varying stature. Adults, adolescents, and children all assign more positive
attributes to tall persons than short persons (Biller, 1968; Gillis, 1982; Martel &

Biller, 1987; Morrow, 1984; Stafferi, 1967). For example, children from 5 to 13

8

years-old were asked to allocate an assortment of characteristics to 3 human
silhouettes of different sizes. The shortest silhouette was described as "unsuccessful,"
"weak, " " follower, " and "no friends." In contrast, the tallest silhouette was
considered " smart, " strong, " "leader, " and "brave" (Clopper, Mazur, & Ellis, 1990).
Among college undergraduates, both males and females associated positive attributes
with tall men and negative qualities with short men (Martel & Biller, 1987). Tall
men were ascribed adjectives such as dominant, optimistic, confident, capable, and
masculine. There also exists a perceptual distortion of height based on ascribed social
status. For example, adolescent males assigned occupations of higher prestige to
individuals perceived as taller (Morrow, 1984), and adults increase their estimates of
an individual’s height as the individual’s reported professional status increases
(Wilson, 1968).

These perceptual biases appear to be even more pronounced in individuals
who view themselves as below average in height. For example, Morrow (1984)
found that the correlation between assigned occupational prestige and stature was
stronger for males who perceived themselves as short. In addition, although short
undergraduate males reported feeling as satisfied with their stature as their taller
peers, they desired an ideal height which was more discrepant from their actual height
than males of average or tall stature (Martel & Biller, 1987). The shorter group of
men also placed greater importance on height in obtaining a dating partner and in
professional success than average or tall men.

The concerns of short males regarding the impact of stature on professional

9
status are based in the reality that height impacts one’s likelihood of being hired for a

job, one’s starting salary, and salary increases (see Gillis, 1982). For example,
within the same profession, workers of tall stature hold higher positions than those
who are shorter, even after accounting for the effects of education and social status
(Schumaker, 1982). One of the most poignant examples of heightism in American
culture is reflected in our presidential elections. In 80% of the 20 presidential
elections from 1904 to 1980 the taller candidate has won (Gillis, 1982). According
to Martel and Biller (1987), "Given such a set of environmental circumstances,
stereotyping, and cultural expectations, it is clear that a myriad of difficulties
confronts the short male in terms of negotiating and solidifying a positive male
identity " (p. 6).

From the discussion above, it is evident that the majority of studies on social
stigma and stereotyping associated with stature has focused on males. This is due in
part to cultural preferences regarding stature. Males make global evaluations about
their bodies and value large stature and strength. By contrast, females make more
specific evaluations about their various body parts and value smallness, except in the
breasts (Fisher, 1986; Martel & Biller, 1987). Masculinity is associated with a tall
well-muscled physique, whereas femininity is often associated with petite stature. In
addition, feelings of being too thin are associated with lower self-esteem in boys,
while feeling too heavy is related to decreased self-esteem in girls (Walsh & Wardle,
1993). Adolescent boys’ ideal is to mature early and have a tall and heavy physique,

while girls generally prefer to mature at a rate consistent with their peers and to be of

10
average height and weight (Frazier & Lisonbee, 1960). These differences partially

account for the higher referral rates of boys for treatment of SS than girls (Clopper,
1992). Both males and females, however, are likely to experience negative
consequences as a result of SS, especially as females increasingly take on more

competitive roles academically, athletically, and professionally.

Self-Image, Self-Esteem, and Self-Competence

Global self-esteem has been described as generalized feelings of acceptance,
goodness, self-acceptance, self-respect, and worthiness (Crocker & Major, 1989).
Self-image, or one’s "multidimensional representation of oneself" (Clopper, 1992) has
been associated with one’s self-esteem. Several researchers of the development of
self-image assume that exposure to social stigma in general (Crocker & Major, 1989),
and that related to SS in particular (Martel & Biller, 1987), has a deleterious effect on
self-esteem. However, there is no clear empirical evidence that members of various
stigmatized groups (e.g. , racial minorities, individuals with physical or mental
handicaps), including those with SS, necessarily suffer from lowered self-esteem.
Clopper (1992) contends that "it appears possible for children to have a poor image of
their physique due to SS while maintaining high levels of overall self-esteem and self-
worth" (p. 28).

Crocker & Major (1989) propose three mechanisms by which the self-esteem
of stigmatized individuals is protected: 1) attributing negative feedback to one’ s

membership in a stigmatized group, 2) comparing oneself with others in the

11

stigmatized group, and 3) selectively devaluing areas in which their group does poorly
and valuing those in which their group excels. The first two strategies might be
somewhat more difficult for the child with SS to utilize, as they have limited access to
others with SS and hence less identification with a SS group as a whole. However,
for children with a family history of SS there is greater exposure to other individuals
with a similar condition and its attendant difficulties. Identification with the group
and social comparison are thus more likely to occur in children with a family history
of SS, as is modeling after adult figures who have successfully (or unsuccessfully)
weathered the experience of growing up with a stigmatizing condition. On the other
hand, for children with no available role models or peers with SS, selective valuing
might be the most effective method in protecting their self-esteem.

Harter (1986) found that children who valued most the abilities in which they
felt especially competent had high self-esteem. It appears that their ability to devalue
areas in which they were less proficient helped to augment their feelings of self-
worth. Of particular interest to the present study is Harter’s (1986) finding that all
children had some difficulty in devaluing physical appearance (as well as cognitive
competence and behavioral conduct). Those children who rated themselves low on
these domains also had lower global self-esteem. By contrast, athletic ability and
social acceptance were more easily discounted if children felt less competent in these
domains.

Dissatisfaction with one’s perceived physical attractiveness has also been

strongly associated with dysphoria in 9-12 year-olds of normal stature (McCabe &

12

Marwit, 1993). In addition, viewing one’s body as ineffective was moderately linked
with dysphoric mood. These results were similar for both males and females. Along
similar lines, self-image and depression were highly correlated in a sample of
adolescents of normal stature, and self-image was the strongest predictor of recovery
from depression as compared to age, education, SES, initial levels of depression, and
life stressors (Fine, Haley, Gilbert, Forth, 1993). Furthermore, a sense of mastery
was one of the most important components of the relationship between depression and
self-image. Thus, it is likely that children with SS who feel positively about their
physical appearance would have higher global self-esteem and fewer feelings of
depression. Conversely, children with SS who are less satisfied with their bodies,
may suffer from lower self-esteem and greater symptoms of depression.

Bukowsi and Newcomb’s (1983) investigation of peer experiences and identity
formation in early adolescence dovetails with the preceding studies. These
researchers found that young adolescents’ feelings of self-worth were related to their
perceptions of social, cognitive, and physical competence. Among these variables,
the strongest relationship was between social competence and global self-esteem.
Social competence was more strongly related to physical competence for boys than
girls, and social acceptance was more closely associated with perceived social

competence for girls than boys.

Juvenilization: Living up to Expectations?

The visibility of body size makes it a significant feature of self-

13

presentation and likely to be of special importance in the development
of a child’s sense of self. Parental judgement of the child whose shape
doesn’t measure up to expectations may disturb children’s natural
response to eating and physical activity and foster self-criticism (Walsh
& Wardle, 1993, p. 1125).

Juvenilization, or being treated in accordance with one’s height age rather than
chronological age, is one of the most prevalent and persistent difficulties confronting
individuals with short stature and delayed maturation. Because stature is one of the
most visible and salient characteristics of an individual, others constantly respond to
this external stimulus in ways which are developmentally inappropriate. This
dissonance between others’ views and expectations and one’s true abilities begins
early in life for individuals with short stature, and may influence the individual’s self—
perceptions both directly and indirectly, through comparison with others and through
the processing of others’ expectations (Eisenberg, Roth, Bryniarski, & Murray,
1984). Although much of the research in this area focuses on adult populations, a
few studies have demonstrated that the social effects of stature begin as early as
toddlerhood and continue into the elementary school years and beyond (Brackbill &
Nevill, 1981; Eisenberg et al., 1984).

Eisenberg and her colleagues (1984) conducted three separate studies
investigating the relationship between preschoolers’ height, adults’ attributions about
the children, and the cognitive and social competencies of the children. In the first

study, mothers of preschoolers viewed an array of two 19 month-old boys which

14
were photographed in such a manner so that the boys appeared to be different heights.

In the first array, child I appeared taller; in the second, child 2 appeared taller; and
in the third, the boys appeared to be of equal height. The mothers were asked to
complete a questionnaire which assessed their perceptions of child competency,
assignment of punishment for hypothetical transgressions, and estimates of the
children’s ages. Significant differences related to height were found for 10 of the 12
items tested, and taller boys were consistently viewed as being more competent.
There were no height effects for the assignment of punishment or estimates of the
children’s ages.

In a second parallel study, mothers of preschoolers were shown stimulus
photographs of two girls aged 19 and 20 months (Eisenberg et al., 1984). On 5 of
the 12 test items there were significant differences related to height. In each case,
shorter girls were perceived as less competent than girls of average or tall height,
whereas tall and average height girls were not viewed differently. Mothers tended to
view the shorter girls as more dependent and helpless, but not less compliant or
socially inept. Mothers rated the smaller girls as significantly younger than either
girls of average or above average height. In addition, greater punishment was given
to taller girls than to smaller girls, regardless of the perceived age of the child.
Taken together, these two studies have implications for the expectations and
reinforcements children might receive based on their stature. The authors interpret
these results as demonstrative of cultural stereotypes such that smaller girls are

considered more "feminine" (e.g. , dainty, defenseless, cute, dependent) and taller

15

boys are considered more "masculine" (e.g. , strong, competent, dominant).

In a third study, Eisenberg et a1. (1984) investigated the relationship of
preschool children’s height to their cognitive development and to peer evaluations of
competency. Boys’ but not girls’ performance on Piagetian tasks of logic was
positively associated with height, after controlling for age, but there were few
relationships between height and peer ratings of competence. Taller boys were rated
as smarter by girls, and smaller boys were rated as better at art projects by both boys
and girls. There were no height effects for peer judgments of girls’ competence. In
light of data suggesting that intelligence is unrelated to the stature of young children
(Bayley, 1956), the authors conclude that taller boys’ better cognitive performance
and greater popularity might be due to responses from their social environment, rather
than superior innate abilities. They suggest that parents (and other adults) might be
more active in shaping the cognitive development of boys than girls, and that this
would be especially true for taller boys, who elicit expectations of greater
competency.

Brackbill and Nevill (1981) found similar results in their studies investigating
the effect of children’s height on parental expectations of achievement. In their first
study parents of 11 year-old children were shown two sets of stimulus pictures
depicting male and female children of different heights, all presumed to be 11 years-
old. Parents were asked to assign 9 chores to each of the 5 children (either all male
or female). In spite of knowledge of the children’s chronological age, parents

consistently had greater expectations of mastery and competence for the taller

16

children, regardless of gender. In the second study three groups of female adults,
with varying degrees of experience with children, were shown two sets of pictures
depicting two same—sexed children. In the first picture the children were the same
height but were assigned different ages. In the second picture the children were
different heights and the younger child was taller. Subjects assigned chores of
varying difficulty to each of the children. Similar to the results in the first study,
female adults assigned more difficult tasks to the taller children, regardless of age.
Consistent with Eisenberg et al.’s (1984) results, these findings suggest a strong link
between parental expectations for achievement and competence and children’s height.
They also lend support to the notion that the degree of children’s achievement
motivation may stem from the presence or lack of parental (and other adult) pressure

to achieve (Brackbill & Nevill, 1981).

P_sychosocial Adjustment to SS
Psychosocial Outcomes in Childhood and Adolescence

Cognitive Functioning and Academic Achievement: Recent
investigations of children with GHD and CD consistently report high rates of grade
retention and academic underachievement. In their investigation of grade retention
and academic achievement in a mixed sample of children with SS (CD, Turner
Syndrome [TS], and GHD), Holmes, Thompson, and Hayford (1984) found that 21%
of their subjects had been retained at least one grade. In spite of average intelligence,

the retained children demonstrated a constellation of difficulties including: lower

l7

verbal and performance abilities, greater conduct- and personality-disordered
problems, and continued poor academic achievement, despite grade retention.
Etiology did not appear to have an effect on grade retention, even though this sample
included girls with Turner Syndrome, who have well-documented nonverbal and
visual-spatial deficits. Those most likely to be retained were adolescent girls and
young boys.

In a sample of adults with GHD, 41% of all subjects repeated at least one
grade, 10% repeated more than one grade, and elementary school grades were the
most commonly repeated (Clopper et al., 1986). 81% of those repeating a grade did
so in primary school, and of this group 62% repeated kindergarten or first grade.
These differences may reflect a growing awareness of and sensitivity to psychosocial
issues confronting children with differences, and a trend not to retain a child solely
because of physical immaturity or size.

Although there has been some conflicting data regarding the cognitive and
academic functioning of children and adolescents with SS, there is general agreement
that academic underachievement is a common problem in this population. Three
theories have been proposed to explain this high incidence of academic failure: 1) the
low ability theory, 2) the cognitive deficit theory, and 3) the cognitive
underfunctioning theory (Siegel, 1982). According to the low ability theory, low
achievement is consistent with subnormal intellectual abilities which are secondary to
endocrine dysfunction. The cognitive deficit theory holds that underachievement is

related to specific cognitive, visual-spatial, and attentional deficits. Finally, the

18

cognitive underfunctioning theory proposes that discrepancies between intellectual
abilities and academic achievement are secondary to psychosocial and environmental
factors, such as low self-esteem resulting from SS and poor parenting (Siegel, 1990).
Each of these theories has gained some degree of support from the existing body of
literature.

One of the most recent and comprehensive investigations of the intellectual and
academic functioning of children with SS began about ten years ago through a
collaborative effort of investigators throughout Michigan. In the first of these studies,
Siegel (1982) examined the cognitive and affective functioning of 42 children with
GHD. Two subgroups were included: 27 subjects experienced SS related to isolated
growth hormone deficiency (IGHD), while 14 had SS secondary to multiple hormone
deficiencies (MHD) which affected their growth hormone secretion and uptake.
Subjects were between the ages of 6 and 16 years and were assessed with the
Wechsler Intelligence Scale for Children-Revised (WISC-R). Overall intelligence fell
within the low average range with a significantly higher incidence of verbal-
performance differences than the normative sample. As a group, the GHD children
had lower scores on the freedom from distractibility factor of the WISC-R. The
freedom from distractibility factor is comprised of the arithmetic, digit span, and
coding subscales, and low scores on this factor indicate difficulties with attention,
sequencing, concentration, and short-term memory. Visual-spatial deficits and lower
math achievement were also evident in 38 % of the sample. Despite these academic

difficulties, these children did not rate themselves as having lower self-esteem than

19

the normative sample, and their mothers did not report behaviors indicating
overprotectiveness. Subjects with MHD had developmental histories which were
marked by significantly more delays and vulnerabilities than the IGHD group.
Mothers of children with MHD were more overprotective than mothers of children
with IGHD, perhaps in response to the perception of their children as more
vulnerable.

In a three-year follow-up study, Siegel and Hopwood (1986) found
achievement problems in 52% of the children with GHD, with over 33% failing at
least one grade in school. Learning problems were assessed with the reading and
math subtests of the Wide Range Achievement Test and the reading comprehension
section of the Peabody Individualized Achievement Test. Underachievers (those who
demonstrated learning difficulties) were significantly more likely to have repeated a
grade, and had significantly lower scores on measures of intellect, achievement, and
visual-spatial skills than those without learning problems. By contrast, there were no
differences between achievers and underachievers on self-esteem and maternal
attitudes. With regard to the three aforementioned theories explaining
underachievement, 40% of the underachieving children had profiles compatible with
the low ability theory; 36% were consistent with the cognitive deficit theory; and the
underfunctioning theory applied to 24%. In the context of average abilities, the
children in the underfunctioning group did not have lower self-esteem or more
protective mothers. Of note is the fact that as a group, the children with GHD rated

themselves higher on self—concept than the normative sample (Siegel & Hopwood,

20

1986). The authors suggest that other factors not measured in the study may have
accounted for the academic problems in the underachieving group, such as motivation,
anxiety, or stress (Siegel & Hopwood, 1986).

The third Michigan study was a seven-year follow-up of 28 of the original
subjects (Siegel et al., 1988). As assessed by the WISC-R, overall intelligence for
the children and adolescents with GHD remained stable (in the low average range),
and scores were lower on the freedom from distractibility scale than the performance
or verbal scales. Visual-spatial skills showed improvement and fell within the normal
range, which was consistent with this group’s low average cognitive abilities.
Improvement was also noted in subjects’ self-concept, particularly in the areas of
physical attraction and popularity, however, academic underachievement problems
persisted in about one third of the sample, with 74% of the original underachievers
having continued difficulties. As a group, underachievers had lower freedom from
distractibility scores than verbal or performance scores on the WISC-R. In addition,
their parents rated them as having significant problems with immaturity and
hyperactivity, characteristics associated with attention problems. These results are
consistent with those of other researchers (Abbott et al., 1982; Lewis et al. , 1986;
Ryan et a1. , 1988), and suggest that both attentional and cognitive deficits play an
important role in the underachievement of children with GHD (Siegel, 1990).

Compared to the extensive research on academic and intellectual functioning in
children with GHD, fewer studies have investigated this area in children with CD and

F88. Only one study includes both individuals with F88 and CD (Gold, 1978).

21

Results suggest that children with CD have greater learning problems, and are
diagnosed with attentional and hyperactivity problems more frequently than their
counterparts with FSS. In addition, half of the children with CD had been described
as immature in school or medical records, while this was true for only 1 out of 435
children with FSS.

Gordon and his colleagues (Gordon et al., 1982; Gordon et al., 1984)
compared 24 children with CD to a group of healthy children, matched for gender,
age, and SES. They found no differences between the groups on measures of
academic, intellectual, or visual—motor functioning (Gordon et a1. , 1984). However,
children with CD were rated by their parents as having significantly more somatic
complaints, schizoidal tendencies, and social withdrawal (Gordon et al. , 1982).
Parents of children with CD also reflected greater difficulties setting clear limits,
though they did not appear to be overly protective. Families with short children were
also described as having poorer cooperation and communication. Children with CD
reported lower self-concept, reflected by greater unhappiness and feeling unpopular.

In a review of the literature on the psychosocial correlates of short stature and
delayed puberty, Lee and Rosenfeld (1987) conclude that overall, children with short
stature have average intellectual abilities, in spite of their somewhat depressed scores
on standardized tests. They also report that there is no conclusive evidence that short
stature is associated with psychopathology or impaired school performance. In a
more recent review article on the psychological impact of SS, Siegel, Clopper, &

Stabler (1991) summarize:

22

"to date, the only clear conclusion is that many significantly short
children have learning problems in school, and that a combination of
cognitive, physiological and psychosocial factors appear to contribute.
However, it has not yet been determined whether specific learning
profiles are more likely to be associated with specific diagnostic

classifications" (p. 15).

Psychosocial Functioning and Social Competence: From the
discussion above, it is apparent that no one conclusion can be drawn about the
psychosocial functioning of children with short stature, as the data are fraught with
inconsistencies. Whereas earlier investigations concluded that children with 88
suffered from impaired self-esteem, more recent studies indicate that children with SS
differentiate between separate areas of their self-concept, and that all are not
uniformly low (Young-Hyman, 1990). It has also been suggested that by devaluing
physical appearance, children with SS are able to maintain adequate global self-worth,
and to derive esteem from those areas in which they feel most competent (Clopper,
1992; Crocker & Major, 1989). In contrast to reports of children with SS feeling
unhappy or unpopular (Gordon et a1. , 1982; Rotnem et a1. , 1977), many children and
adolescents with 88 rate themselves as having high, somewhat elevated self-esteem
(e.g., Young-Hyman, 1986). Furthermore, many children with SS are able to make
accurate appraisals about their stature (Young-Hyman, 1986) and report satisfaction

with their physical appearance (Gordon et al., 1982).

23

With regard to social competence, children with S8 have demonstrated a
pattern of social withdrawal, immature behavior, and a preference for individual
rather than group activities (Gordon et al., 1982; Holmes et al., 1982, 1984; Young-
Hyman, 1986). Short children tend to have fewer, but more long-term close
friendships (Young-Hyman, 1986). These results may be due in part to the short
child’s fear of social situations in which s/he might encounter teasing, juvenilization,
social ostracism, or negative feedback regarding performance or capabilities.
According to Stabler and his colleagues (1980), "Not only does short stature limit the
range of social roles available to the individual, but, in addition, short children tend
to exhibit social behaviors which accentuate the discrepancy between their
chronological age and physical stature " (p. 743).

There is some evidence that children with SS have impaired social judgment,
low tolerance for frustration, and decreased competitiveness and aggressiveness
(Drotar et al., 1980; Holmes et al., 1982; Stabler et al., 1980; Steinhausen &
Stahnke, 1976; Young-Hyman, 1986). For example, Young-Hyman (1986) found that
children and adolescents with CD, FSS, and GHD scored significantly lower on a
social problem-solving task than the normative sample. In spite of this difficulty,
subjects rated themselves as more competent than age norms in social skills, self-
esteem, and cognitive abilities. Along similar lines, Drotar et a1. (1980) studied
frustration tolerance and problem-solving in children with SS. This sample of
children with GHD had low tolerance for frustration, and poorer, less adaptive and

mature problem-solving skills.

24

In their investigation of social judgments and competitiveness in children with
SS, Stabler and his colleagues (1980) administered a test of cause and effect in social
situations under competitive and noncompetitive conditions to a group of male
children with SS and a group of age-matched male children with normal stature.
While the children with SS demonstrated lower social judgment abilities than matched
controls under both conditions, they did exhibit an increase in scores during the
competitive trial. These results provide evidence that under conditions of increased
competition, children with SS have appropriate levels of motivation to achieve.

It can be argued that adolescence would be a period of particular challenge for
the individual with SS, as delayed physical and sexual maturation would become more
prominent in the context of peer attainment of puberty, and might thwart or retard the
normative developmental processes of identity formation, individuation, socialization,
and psychosexual mastery (Dean et al., 1986). Holmes et al.’s (1986) longitudinal
study of the psychosocial correlates of SS lends support to the hypothesis of increased
distress during adolescence. Subjects were children and adolescents who had been
followed for three years after their initial evaluation for SS due to GHD, CD, or
Turner Syndrome (TS). Results indicate that the subjects experienced an age-related
decline in adjustment during adolescence, with decreases in school and social
competence at 12 and 14 years of age. During this period psychosocial functioning
fell to about 1 SD. below the mean, while it was preceded and followed by
functioning at the 50th percentile. By approximately 17 years of age, school and

social competence had normalized. The most significant academic problems were

25
experienced by adolescent females (primarily those with TS and GHD), whose

performance was 1.5 SD. below the mean. By contrast, younger children with CD
had the highest academic performance, and boys generally performed at their
expected age levels. Overall, younger children with SS exhibited more behavior
problems and demonstrated significantly more externalizing and internalizing
behavior problems (e.g. , social withdrawal and somatic complaints).

In their investigation of boys with CD and GHD, Holmes, Hayford, and
Thompson (1982) found no differences in behavior patterns based on diagnosis. They
did, however, find that age was a more important factor in psychological adjustment
than specific diagnoses. Older boys with SS were rated by their parents as having
significantly more obsessive-compulsive and less aggressive tendencies than younger
boys, and older boys were more conforming and inhibited. Parents rated both age
groups as significantly more withdrawn than the normative sample for the measure.

Taken together, the data concerning the psychosocial adjustment of children
and adolescents with SS depicts a fairly well-functioning group, with specific deficits
in academic and social competence. Younger children appear to have greater
behavior problems in general, while adolescence is characterized by more
internalizing behavior problems and deficits in self-competence. While there is little
empirical evidence suggesting significant differences in the psychosocial functioning
of boys and girls, the literature on social stigma and stereotypes supports the
hypothesis that girls with SS will experience fewer psychosocial difficulties. This is

partially supported by the higher referral rates of boys to specialty clinics for

26

concerns about stature. Until the research in this area takes on a more biopsychosical
and systemic approach, however, no firm conclusions can be drawn regarding the
multiple factors which affect child adjustment to SS. As Siegel (1990) aptly
summarizes the current state of affairs, "the literature to date is glaringly void of
studies investigating family interactional patterns in terms of the differences that
cohesiveness, adaptability, and triangulation may have on the overall functioning of
these physically and psychologically vulnerable children" (p. 37). The present study
represents an attempt to fill this gap in the existing body of literature by addressing

the family factors and processes that impact children’s psychosocial adjustment to SS.

Psychosocial Outcomes in Adulthood

The long-term psychosocial outcomes associated with SS have been
documented primarily in adult populations of individuals with GHD, many of whom
had received growth hormone therapy as children and/ or adolescents. These data
provide a somewhat disconcerting picture of adult psychosocial functioning in
individuals with SS, and in particular those with GHD. Lower rates of employment
and marriage are consistently reported in this population than in matched control
groups or regional norms (Bjork, Jonsson, Westphal, & Levin, 1989; Clopper,
MacGillivray, Mazur, Voorhess, & Mills, 1986; Dean, McTaggart, Fish, & Friesen,
1986; McGauley, 1989; Mitchell, Libber, Johanson, Plotnik, Joyce, Migeon, &
Blizzard, 1986; Ranke, 1987). Of note is that rates of employment and marriage in at

least one population of adults with GHD are lower than those found in populations of

27

adults with other chronic diseases (Dean, McTaggart, Fish, and Friesen, 1986).
Furthermore, these relatively poor psychosocial outcomes appear to be unrelated to
final adult height attained (Dean et al., 1986; Zimet et al., 1993). Many of these
adults with GHD did not live independently from their parents and fewer obtained
driver’s licenses than in comparable age groups (Bjork et al., 1989; Clopper et a1. ,
1986; Dean et al. , 1986) The majority of these subjects report that juvenilization
continued to impact their lives negatively both professionally and socially in adulthood
(Clopper et al., 1986; Dean et al., 1986; Mitchell et al., 1986). Adults with SS also
have reported lower quality of life, greater social isolation, greater health problems,
more anxiety and depression, higher rates of participation in counselling, and lower
feelings of well-being than adults of normal stature (Bjork et al., 1989; Dean eta 1.,
1986; McGauley, 1989; Mitchell et al., 1986).

By contrast, in Mitchell et al.’s (1986) study of adults with GHD, subjects
rated themselves as higher on self—satisfaction, personal worth, and sociability, and
lower on physical attributes and self-criticism than a comparison group. The authors
interpret these results as indicating a significant degree of denial and repression in
their sample of adults with GHD (Mitchell et al., 1986). Zimet and his colleagues
(1993) also report higher rates of restraint and repressive defensiveness in his sample
of short adults without GHD than in a normative sample. Finally, despite an
improvement in height, those individuals who received GH therapy were still
significantly short as adults and continued to manifest numerous psychosocial

difficulties (e.g., Dean et al., 1986; Bjork et al., 1989). On the other hand, many

28

researchers argue that compared to adults of normal stature, those with SS do not
demonstrate significantly more psychosocial distress and live productive and fulfilling

lives (e.g., Clopper et al., 1986; Mitchell et al., 1986; Zimet et al., 1993).

Family Factors and Child Adjustment to SS

Conflict, Control, and Support: There is evidence that having a child with
medical concerns results in the perception of the child as "vulnerable" (Green &
Solnit, 1964; Thomasgard & Metz, 1995). This process has also been reported in
parents of children with SS (Rotnem et al. , 1980) and may exacerbate parents’
existing concerns about a child who is physically challenged and different from
his/her peers. This view of the child with SS as vulnerable or at risk can result in
parent-child interactions which promote juvenilization, overprotection, difficulty
setting appropriate limits, overconcerns with bodily functioning, and academic
underachievement (Clopper et al. , 1986; Rotnem et al., 1977; Young-Hyman, 1986).
The psychosocial competence of children with SS can be fostered, however, within a
nurturing and supportive family environment in which parents encourage age-
appropriate behavior and development (Abbott et a1. , 1982; Rotnem et al., 1977;
Young-Hyman, 1986).

The dimensions of family support, control, and conflict have long been
implicated as important factors impacting children’s psychosocial adjustment in
general, and self-esteem in particular. For example, Hoelter & Harper (1987)

examined a number of family variables (family size, composition, conflict, and

29

support) and their relationship to adolescent self-esteem. These authors found that
family support was the most important family factor in the development of adolescent
self-esteem and identity salience for both boys and girls. In addition, family conflict
was negatively related to adolescents’ self-esteem. Parental authoritarianism and
control also have also been linked to lower self—esteem in adolescents (Buri et al.,
1988; Buri, 1989; Demo et al., 1987), while authoritative parenting is positively
related to adolescents’ self-esteem (Buri, 1989). Children’s perceptions of family
support and cohesiveness are positively related to their self-esteem, while their
perceptions of family conflict are inversely correlated with self-esteem (Cooper et al.,
1983). Further, adolescents’ perceptions of good communication and participation
with their parents is associated with higher self-esteem.

Gecas and Schwalbe (1986) found gender differences in the relationship
between parent behaviors (support, control/ autonomy, and participation) and
adolescents’ self-perceptions. Boys’ self-esteem was more affected by the
control/autonomy dimension, while girls’ self-esteem was more dependent on parental
participation and support. Fathers’ behaviors were more consequential than mothers’
for the development of self-esteem, especially for boys. Of note is that children’s
perceptions of the family environment, rather than the parents’ , are more strongly
associated with children’s reports of self-esteem (Demo et al., 1987; Gecas &
Schwalbe, 1986).

The family factors of support, control, and conflict have also been linked to

children’s behavioral, social, and academic competence. There is a particularly large

30
body of literature linking family conflict, especially conflict between parents, to child

behavior problems (see Block et al., 1981, 1986; Christensen et al., 1983). The
relationship between parental conflict and child behavior problems has been stronger
for boys than for girls (Emery & O’Leary, 1982; Block et al., 1981, 1986). Parental
discord has also been related to children’s feelings of unacceptance (Emery &
O’Leary, 1982). In adolescent populations, family conflict has been associated with
poorer psychological adjustment, increased anxiety, lower self-esteem and life
satisfaction, and lower feelings of control (Enos & Handal, 1986; Slater & Haber,
1984). In addition, Moos and Moos (1986) report that a supportive and stimulating
family environment is most conducive to children’s social and cognitive development.
Further, they report that families characterized by structure and support foster
children’s scholastic self-concepts, while highly controlling and conflicted families do
not. Finally, in a group of children with poor school performance, greater behavior
problems (particularly internalizing behaviors) were found in children whose families
were less supportive and more controlling (Thompson et a]. , 1990).

Family functioning has also been strongly associated with both child and
parent adjustment to childhood chronic illnesses. According to Moos and Moos
(1986), "In general, supportive family environments, characterized by high cohesion
and expressiveness and low conflict, are associated with family members’ better
adjustment and greater ability to deal with stress, especially when coping with
personal physical illness or a spouse’s mental and behavior problems, " (p. 30).

Similarly, Thompson and his colleagues (1992a) found that mothers of children with

31

cystic fibrosis demonstrated higher levels of adjustment when their families were
supportive and less conflicted.

Kronenberger and Thompson (1990) derived three factors from the Family
Environment Scale (Moos & Moos, 1986) in a sample of families with chronically ill
children: supportive, conflicted, and controlling factors. Chronically ill children
whose families were supportive had fewer internalizing behavior problems and higher
scores on sociability. In addition, children from conflicted families had more
externalizing behavior problems and lower scores on sociability. The results
underscore the family’s ability to moderate the effects of stress on the functioning of
children and their families. In a sample of adolescents with spina bifida, Murch and
Cohen (1989) found that low family conflict and control buffered the effects of
stressful life events on the adolescents’ psychological adjustment. Family conflict has
been associated with externalizing behavior problems in a group of children with five
different chronic illnesses (W allander et al. , 1989). On the other hand, family
cohesion and expressiveness were positively related to social competence, while
control was negatively related to social competence. These "psychological family
resources" accounted for a significant amount of the variance in the chronically ill
children’s psychological and social adjustment, beyond that accounted for by "family
utilitarian resources" (i.e. , maternal education and family income). Family
communication and ability to resolve conflict have also been related to adolescents’
adjustment to diabetes (W ysocki, 1993). Along similar lines, patients with

psychosomatic disorders tend to come from families which are relatively high on

32

control (Waring & Russell, 1980). These results are consistent with the clinical
observations of Minuchin and his colleagues (i.e., Minuchin, Rosman, & Baker,
1978).

In sum, this body of research indicates that the family environment has
important effects on child self-esteem, and academic and psychosocial competence.
These results are consistent across families with healthy children and children with
chronic illness. In particular, families that are characterized by mutual support,
authoritative parental control which encourages age-appropriate child mastery, and
low levels of conflict, buffers the stresses associated with child chronic illness in both
parents and children. Within this family environment, optimal levels of parental and
child adjustment are possible, in spite of the many challenges imposed by child
chronic illness. These family factors of support, control, and conflict, are deemed
equally important for the psychosocial adaptation of children with SS. Short stature is
comparable to other childhood chronic illnesses in many ways: its chronicity, the
somewhat uncontrollable nature of its course, the need for long-term medical
interventions and sometimes invasive procedures, the emotional and financial stresses
it places on the child and family, parental concerns about treatment decisions and the
child’s physiological and psychosocial development, and its constant threat to the
child’s sense of mastery, independence, and control. Therefore, it is hypothesized
that high levels of family support, low levels of control, and low levels of conflict
will predict higher levels of child self-esteem and psychosocial competence in children

with SS.

33
Parental Self-Esteem and Impact of Stature: The relationships between a)

parental self-esteem and child adjustment, and b) parents’ stature experiences and
child adjustment, have only been examined in a peripheral manner. In their study of
the lineage transmission of interpersonal competence, Filsinger and Lamke (1983)
found strong relationships between parents’ social competence and their older
adolescent’s interpersonal competence and social self-esteem. In addition, children’s
success in intimate relationships was significantly inversely linked to mothers’ social
distress and avoidance. Children’s feelings of social competence were significantly
related to fathers’ social self-esteem. From these limited results we can predict that
higher parental self-competence will be directly related to child self-esteem, and
indirectly related to child psychosocial adjustment, via its effects on child self-esteem.
Even less is known about the relationship of parental experiences related to
stature and its impact on child functioning. One study found that parents who
themselves were short viewed their children with SS as more socially competent than
parents of average stature (Young-Hyman, 1986). This finding may suggest a
compensatory process whereby parents with a history of SS themselves view their
child with SS in a more positive light. It is likely, however, that parents’ experiences
related to stature will have both positive and negative effects on child self-esteem,
coping, and adjustment. This will largely be determined by the degree to which

parents themselves have adjusted to their own experiences related to stature.

Coping Strategies: There are no known studies which directly investigate the

34
coping styles of individuals with SS. In addition, only one study was found that

assesses the relationship between parents’ and children’s defense and coping
mechanisms. No significant relationships were found between the defenses and
coping styles of male children and their fathers, and only moderate associations were
found between mothers’ and sons’ coping styles (Peshkess, 1977). Furthermore, the
description and assessment of children’s coping strategies has only recently begun to
be investigated and there are few standardized instruments available to measure
coping in children (Causey & Dubow, 1992; Knapp et al. , 1991).

Coping has been defined as "constantly changing cognitive and behavioral
efforts to manage specific external and/ or internal demands that are appraised as
taxing or exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 141).
Coping strategies differ as a function of the perceived stress at hand. Problem-
focused coping involves an individual’s attempts to mange or alter a stressor.
Emotion-focused coping represents the individual’s efforts to regulate emotional
distress caused by a stressor. Another taxonomy has been proposed which divides
these mechanisms into approach and avoidance coping (Roth & Cohen, 1986).
Approach coping strategies are "behavioral, cognitive, or emotional activities oriented
toward a stressor (e. g. , seeking information), " while avoidance coping strategies are
"behavioral, cognitive, or emotional activities oriented away from a stressor in order
to avoid it (e.g., ignoring the stressor)," (Causey & Dubow, 1992, p. 47).

In general, avoidance or emotion-focused coping strategies are associated with

poorer adjustment, whereas approach or problem-focused coping techniques are

35
related to more positive functioning (Causey & Dubow, 1992). Using self-report and

peer-report measures of coping with 4th through 6th graders, Causey and Dubow
(1992) found that girls used approach strategies more often, while boys chose
avoidance strategies more frequently. Approach coping was positively associated with
behavioral conduct esteem and global self-worth. Avoidance coping was positively
related to self-reported anxiety, and inversely related to global self-worth and
behavioral conduct. Similarly, Compas et al. (1988) found that in children’s coping
with an interpersonal stressor, emotion—focused coping was associated with greater
self-reports and maternal reports of emotional and behavioral problems, while
problem-focused coping was negatively related to adjustment difficulties. Avoidance
coping strategies were used more often by adolescents with depressive or conduct
disorders than by a healthy control or physically ill control group (Ebata & Moos,
1989).

Studies of parental coping techniques reveal findings which are consistent with
studies of children’s coping reported above. Problem-focused (approach) coping was
associated with decreased psychological distress in mothers of physically disabled
children, whereas emotion-focused (avoidance) coping was related to higher levels of
maternal distress (Miller et al., 1992). Similarly, palliative (avoidance) coping was
associated with poorer adjustment in mothers of children with cystic fibrosis
(Thompson et al. , 1992a).

Given the above evidence linking coping strategies to psychosocial adjustment,

it is predicted that parents’ and children’s use of approach coping strategies will be

36

related to better child psychosocial outcomes, and reliance on avoidance coping

strategies will be linked to poorer child adjustment.

Transactional Stress and Coping Model

Thompson and his colleagues (1992b) have proposed a transactional stress and
coping model for chronic childhood illness which is based on an ecological systems
theory perspective. Within this model chronic childhood illness represents a stressor
to which the individual and family systems attempt to adapt. The relationship
between illness and outcomes is a function of biomedical, psychosocial, and
developmental processes (Thompson et al. , 1992b). Severity is the illness parameter,
and age, gender, and SES are the demographic parameters. The focal point of the
model is child and family processes which mediate the relationship between illness
and outcomes, beyond the contributions of illness and demographic parameters. The
model also includes psychosocial/mediational processes which potentially reduce the
impact of stress. These include: cognitive appraisals of stress, expectations of locus
of control and efficacy, coping methods, and family functioning.

This model was used to investigate the processes in the emotional adjustment
of mothers who had children with cystic fibrosis (Thompson, Gustafson, & Spock,
1992a). Maternal adjustment was not related to the illness severity or demographic
parameters. Adjustment was, however, significantly related to the proposed
psychosocial/mediational processes which accounted for 35 and 40% of the variance

in maternal anxiety and depression, respectively (Thompson et al. , 1992a). Higher

37

maternal adjustment was associated with family supportiveness, low levels of
perceived daily stress, and less reliance on palliative (avoidance) coping methods.
This research model was subsequently expanded to include the processes which
affect the psychological adjustment of children with chronic illness. These
psychological/mediational processes include expectations of locus of control and self-
esteem. Child coping methods are also included in the model, but have not been
empirically tested, for lack of an adequate measure of children’s coping responses
(Thompson et al. , 1992b). Based on an ecological-systems theory perspective, the
authors predicted that child psychological adjustment would be affected by the stress
and symptoms in other family members. This is based on a large body of literature
linking parental depression with child emotional and behavior problems (e.g. , Compas
et al., 1989; Daniels et al., 1987). The results supported the psychosocial
mediational processes of child self-esteem and maternal anxiety in child adjustment.
In particular, children who reported lower self-esteem also had poorer adjustment, as
measured by maternal reports of behavior problems and self-reported distress. The
illness and demographic parameters accounted for only small amounts of variance in
child adjustment, whereas self-esteem accounted for a significant amount of the
variance in child adjustment as reported by both mother and child. Maternal anxiety
also accounted for a significant increase in variance in both mother— and child-
reported child adjustment. These results highlight the interactional nature of parent
and child psychological/mediational processes and their impact on child adjustment to

chronic illness.

38

The present study tested a modified version of the Transactional Stress and
Coping Model of Thompson and his colleagues (1992b) (see Figure 1). Changes have
been made in order to accommodate the variables of interest in the present study
which are thought to be related to children’s psychosocial adaptation to SS. Both
parent and child coping were included in the model, and were assessed with semi-

structured interviews.

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Limitations of Previous Research on SS

The body of literature investigating the psychosocial and cognitive functioning
of children with SS is marked by numerous inconsistencies. Differences in the results
of comparable studies can be accounted for in part by methodological differences and
shortcomings. For example, one of the major limitations of the literature on SS has
been the practice of combining heterogeneous samples of children with SS, some of
whom have well-documented cognitive deficits and physical stigmata (e.g. Turner
Syndrome and achondroplasia). The inclusion of such disparate groups makes it
difficult to isolate the effects of SS on psychosocial adjustment from the effects of
other physical differences or cognitive and behavioral difficulties. In addition,
combining children whose SS is secondary to cranial tumors or radiation for life-
threatening illnesses with children with CD, GHD, and FSS, seems equally
inappropriate. The power of statistical comparisons has been limited by small sample
sizes, some of which do not exceed 15. In addition, few studies provide carefully
matched control groups of children with normal stature. Researchers have not
routinely controlled for socioeconomic status, which is especially important when
studying cognitive and academic functioning.

With regard to measurement issues, earlier studies on the psychosocial
functioning of children with SS suffered from a lack of standardized and well-
validated test instruments. Many of these investigations relied on anecdotal data. In
addition, there has been a lack of consistency in the definitions of the operational

constructs studied (Siegel, 1990). The majority of studies in this area have relied on

41

parent—, teacher-, or self-report measures. While these are all valuable sources of
information which provide different perspectives, they are subject to defensive or
otherwise biased responding. As discussed above, it is clear that denial and
repression are common in both children and adults with SS (Siegel & Hopwood,
1986; Voss et al., 1993; Zimet, 1993), which brings into question the reliability of
the subjective measures curently in use. Qualitative research methods (e.g. , semi-
structured interviews) might allow for more in-depth querying and clarification when
denial or minimization is thought to occur. Interview data could corroborate
information obtained in self—report measures.

By far the most serious shortcoming of this body of research is the failure to
address family factors which might impact children’s psychosocial adjustment to SS.
There is a clear need for a more systemic focus, which includes both parent and child
perceptions and experiences, and addresses the relationships between these variables.
Those studies that do include family factors are usually based on maternal reports
only, with relative neglect of fathers’ contributions to children’s developmental
outcomes. Fathers have been shown to be especially important to children’s
developing self-concept (Amato & Ochiltree, 1986), particularly for male children
(Gecas & Schwalbe, 1986). In addition, as Rotnem et al. (1982) found that fathers
had greater difficulty accepting the diagnosis of SS than mothers, it is likely that their
responses will have important implications for child adjustment to SS. Finally, there
have been no investigations which look at the relationship between parental

functioning (e.g. , self-esteem, coping strategies) and child adjustment to SS. This

42

may be especially important when parents themselves have a history of SS.

Overview and Research Questions

The present study was designed to improve upon past methodological
weaknesses in the literature on child psychosocial adjustment to SS as follows:
1) While the current sample of children includes mixed diagnoses (CD, GHD, FSS,
and CD/FSS), it does not include diagnostic categories in which affected individuals
have additional cognitive, physical, or psychological difficulties (e.g. , TS,
achondroplasia).
2) The psychosocial adjustment of children with SS was compared to that of a group
of children with normal stature, matched for age, gender, ethnicity, and SES.
3) A major focus of this study was to test a stress and coping model for SS,
including family and child psychological and mediational processes which were
predicted to affect child outcomes.
4) Both mothers and fathers were included in this study.
5) Questionnaires were combined with a semi-structured interview in order to obtain
more detailed qualitative data on the impact of stature and coping styles of parents
and children.

The following research questions were addressed in this investigation: 1) Do
children with short stature demonstrate significantly more psychosocial and behavioral
problems than a matched group of children of with normal stature?

2) Are there gender, age, or diagnosis effects in children’s adaptation to short

43

stature?

3) Do children with short stature devalue physical appearance as a way of
maintaining overall high self-esteem and positive affect?

4) Do the family environments of children with short stature differ from those of
children with normal stature?

5) How do family factors impact children’s adjustment to short stature?

6) How do the coping styles of parents relate to child coping and child adjustment?
7) Is a model of stress and coping useful for understanding the individual and family

processes which affect child adjustment to SS?

CHAPTER 2

Hypotheses

1) Children and adolescents with SS will be rated by their parents as having
significantly more psychosocial and behavioral problems than a matched group of
children with normal stature.

2) Children and adolescents with SS will rate themselves as having lower self-
competence than a matched group of children with normal stature.

3) Boys with SS will demonstrate greater psychosocial and behavioral problems and
lower self-competence than a) girls with SS, and b) children of normal stature.

4) Younger children with SS (under 12 years) will demonstrate a) greater self-
competence, and b) greater psychosocial and behavior problems than older children
and adolescents with SS (12 years and above).

5) Children with SS who have a perceived or diagnosed family history of SS (F88
and FSS/CD) will demonstrate better psychosocial adjustment than those without a
perceived or diagnosed family history of SS (GHD and CD).

6) Children with SS who devalue physical appearance will have a) higher self-
esteem, and b) fewer internalizing behavior problems than those who regard
appearance as more important.

7) Families of children with SS will be more controlling than families of children
with normal stature.

8) Families factors of a) high support, and b) low control and conflict will be

45

associated with: a) higher child self-esteem, and b) better adjustment (social,
academic, and behavioral competence) both for a) children with SS, and b) children
with normal stature.

9) The type of coping strategies used by parents will be positively related to the type
of coping strategies used by their children.

10) Children’s approach (rather than avoidance) coping strategies will be associated
with better child psychosocial adjustment.

11) The relationship between children’s psychosocial adjustment to SS and
diagnostic/demographic parameters will be mediated by family emotional resources
and mediational processes ( a) support, b) conflict, c) control, d) parents’ self-worth,
e) parents’ impact of stature, and 0 parents’ coping strategies), and child mediational

processes ( a) self—worth, b) impact of stature, and c) coping strategies).

CHAPTER 3
Method

Subjects

Subjects were 33 children between the ages of 6 and 18 years with short
stature (SS) and their parents, and a comparison group of 33 children of normal
stature. There were 23 boys and 10 girls in each group. Participants were recruited
through a university pediatric endocrinology clinic and were at or below the fifth
percentile of height (-1.6 SD) expected for age and gender. Patients with a history of
serious chronic illness, cranial tumor, developmental delay/mental retardation,
achondroplasia, Turner’s Syndrome, chromosomal abnormalities, or physically
disfiguring conditions were excluded from the study. These exclusion criteria were
designed to eliminate other factors which might negatively impact the child and
family’s adjustment to SS. In this manner, the subject population was limited to
children and families whose primary challenge was coping with short stature and its
attendant difficulties. Also excluded were patients who did not speak fluent English.
Eligible participants carried the following diagnoses: 1) hypopituitarism/ growth
hormone deficiency (GHD), including cases of growth hormone deficiency which are
idiopathic or due to pituitary pathology (n=4); 2) familial short stature (FSS), in
which the rate of growth is normal and short stature is linked to genetic inheritance
(n=8); and 3) constitutional delay of growth (CD), in which a delayed rate of growth
causes short stature and delayed puberty, but a normal final adult height is obtained

(11: 16). Four subjects were diagnosed as having both familial short stature and

46

constitutional delay (FSS/CD). One subject had SS of unknown etiology. The
following diagnostic criteria are used in the Michigan State University Pediatric
Endocrinology Clinic where subjects with SS were recruited:
1.) GHD: a) peak GH of < 10 ng/ml after administration of a provocative
stimulus and/or;
b) 24-hr. average concentration of GH < 3.2 ng/ml and;
c) bone age delay > 2 SD’s from chronological age and;
(1) growth rate < 4.2 cm/yr.
2.) CD: a) bone age delay > 2 SD’s from chronological age and;
b) 5th percentile height or below.
3.) FSS: a) 5th percentile height or below
b) bone age within 2 SD’s of age expectancy.

Subjects who have received or were receiving some type of pharmacological
intervention (e. g. , GH) were not excluded from the study, as long as they met the
criterion for height (at or below the 5th %tile) at the time of recruitment. Twenty-
four subjects had never received pharmacological treatment; 3 had in the past but
were not currently; and 6 were currently under treatment (2 for under 6 months and
4 for over six months) at the time of their participation.

Of the 39 potential candidates approached to participate in the study, four
families declined. Three of these families were concerned about possible negative
repercussions of participation and did not want to emphasize their childrens’ SS. The

fourth family was in the process of a divorce. Although the parents were willing to

47

48

participate, the child declined. Two more families agreed to participate, but did not
respond to attempts to contact them after the initial meeting. In three additional
families the children agreed to complete questionnaires, but did not wish to participate
in the interview. In one family, the mother completed questionnaires, but deferred
participation in the interview. Thirty children with SS and their families provided
both questionnaire and interview data, while 3 completed only questionnaire data.

The 33 subjects with SS came from predominantly middle class, Caucasian,
two-parent families. Socioeconomic status was measured by the Revised Duncan
Standardized Socioeconomic Index (TSEIZ) averaging both parents’ scores, as
recommended by Mueller and Parcel (1981). The mean TSEIZ of these families was
40.22 (consistent with managerial and administrative positions) with a range of 17.70
to 76.90 (laborers to professionals). The average yearly income of this group fell in
the $40,000-$49,000 range. The mean age of the children was 11.91 years, with a
range of 6.25 to 17.83 years. Twenty-eight of the children were Caucasian, 2 were
Asian, 1 was Hispanic, and 1 was bi—racial (Caucasian/African-American). Three of
the children were adopted as infants.

A control group of 33 children of normal stature (between the 10th and 90th
percentiles of height for age and gender) who were never referred to a physician
because of concerns related to stature, were matched with the SS subjects on gender,
age (+/- 11 months), SES, and ethnicity. These subjects were recruited through a
primary care pediatric clinic and through flyers circulated within the same geographic

area from which the SS group was drawn (e.g. , at schools, churches, and through

49

personal contacts). The same exclusion criteria discussed above were used in
selecting matched controls. The mean age of this group was 11.65 years with a range
of 5.83 to 17.33 years. Adequate matches were made for ethnicity for all subjects
except one Hispanic girl with SS who was matched with a Caucasian girl of normal
stature. The mean Duncan TSEI2 for the comparison group was 42.80 and was not
significantly different from that of the SS group (t= .59; p= .55). One of the children

in this group was adopted as an infant.

Procedures

Potential SS subjects were identified from a patient roster prior to their
appointment at the pediatric endocrinology clinic. They were sent a letter explaining
the purpose of the study and were informed that they would be called within one
week in order to answer any questions and to discuss their interest in participation
(see Appendix B). If the parent(s) and the child agreed to participate, a meeting with
the primary investigator was arranged either before or after their clinic appointment to
discuss issues pertaining to confidentiality and consent, and to administer
questionnaires and conduct an interview with each family member individually.
Families were assured that confidentiality would be maintained, that their participation
in the study would not impact their medical care in any way, that the information they
provided throughout the course of the study would not be part of their medical record,
and that they could terminate participation at any time. These procedures to ensure

participant confidentiality and ethical treatment have been approved by the University

50
Committee on Research Involving Human Subjects (UCRIHS) (see Appendices C and

D).

Both written and verbal instructions were given for completing the
questionnaires (see Appendix E). Parents and children were instructed to complete
their forms independently and not to discuss their answers until everyone had
completed them. If a child required assistance when the investigator was unavailable,
parents were requested to help their child without influencing responses. In order to
reduce the amount of time required to complete both the questionnaires and
interviews, while one family member completed the interview, the others filled out
their questionnaires. The order of administration of the interview and questionnaires
was randomly alternated so that an equal number of parents and children completed
the interview prior to the questionnaires. All interviews were conducted privately and
were videotaped. In cases where families were not comfortable being videotaped, the
interviews were audiotaped. In some instances, it was not possible to send letters to
potential subjects with SS prior to their appointment at the endocrine clinic because of
late additions to the clinic schedule, schedule or address changes, or uncertainty about
diagnoses. Recruitment then occured during their clinic visit and the interviews were
scheduled at a convenient time for the family.

The comparison group of children with normal stature (NS) was recruited with
flyers in a primary care pediatrics clinic and other community establishments (e.g. ,
churches, sports facilities, childcare centers, and laundromats), and through personal

contacts. Families were screened briefly for exclusionary criteria and for

51

demographic variables, to ensure their appropriateness and match. All other
procedures were the same as those followed with the SS subjects.

While it would have been preferable to conduct all of the interviews in person,
some of the families traveled a great distance to clinic (e.g., over 350 miles) and/or
were unable to stay for the interviews after their appointment, or to return to or meet
at the Clinical Center. Under these circumstances, the primary investigator either
conducted the interviews in the subject’s home or over the telephone. When face-to-
face interviews were not possible, telephone interviews were deemed appropriate and
practical, and they prevented the loss of subjects due to geographic or time
constraints. All phone interviews were audiotaped and families completed their
questionnaires independently at home and returned them in the mail.

A considerable body of literature comparing face-to-face with telephone
interviews lends support to mixing these two methodological approaches. For
example, studies investigating adult hypertension (Chwalow, Balkav, Costigliola, &
Deeds, 1989), psychiatric epidemiology (Fenig, Levav, Kohn, & Yelin, 1993),
depression (Wells, Burnam, Leake, & Robins, 1988), drug use and sexual behavior in
Hispanics (Marin & Marin, 1989), and sexual behavior in college females (Berrnak,
E. , 1989) have found significant agreement between the two methods with no
significant differences with regards to rate and depth of self-disclosure ( e. g., Quinn,
Gutek, & Walsh, 1980), interviewee discomfort, codability, and accuracy of response.
Chwalow et al. (1989) state that "the use of more than one method of data collection

with the same sample, while facilitating the augmentation of the response rate, will

52
not necessarily bias the study results," (p.321). In addition, Rogers (1976) concludes

that "the quality of data obtained by telephone on complex attitudinal and knowledge
items, as well as personal items is comparable to that collected in person," (p. 51).
While this body of data is based on adult subjects, Reich & Earls (1990) conducted a
parallel study with an adolescent population (12-17 yrs.). They found that face-to-
face and telephone interviewing did not differ in the reporting of diagnostic categories
or in response rates to embarrassing or personal questions. Adolescent subjects
interviewed by telephone did, however, report fewer symptoms than those interviewed
in person. There have been no known comparable investigations involving telephone
and face-to-face interviews with children.

A greater proportion of telephone interviews were conducted for the
comparison group than the SS group. In the SS group, 37% of the children, 38% of
the mothers, and 65 % of the fathers participated in telephone interviews. In the
comparison group, 53% of the children, 53% of the mothers, and 81% of the fathers
were interviewed by telephone. This difference was due in part to fewer
opportunities for personal contact with the comparison families, and possibly less

investment on their part in study participation.

Measures
Demographic Parameters/ Instrumental Family Resources
Wallander and his colleagues (1989) have defined utilitarian family resources

as "structural characteristics of the family which may aid in dealing with acute and

53

chronic problems related to the child’s handicap" (p. 376). Previous research has
included the following characteristics as utilitarian or instrumental family resources:
parents’ age and education, family income, family size, and duration of marriage. In
the present study, each parent completed a Child and Family Information
Questionnaire in order to provide information regarding family demographics as well
as instrumental family resources such as: parents’ ethnicity, education, employment

status, family size, and gross annual income (see Appendix F).

Family Mediational Processes

Psychosocial Family Resources: The psychosocial family resources of
interest in the present study include family support, control, and conflict. These three
factors were assessed with the Family Environment Scale-2nd Edition (FES-Moos &
Moos, 1986) and the Children’s Version of the Family Environment Scale (CVFES-
Pino, Simons, & Slawinowski, 1984). The FES is a 90-item true-false questionnaire,
comprised of 10 subscales, designed for adolescents and adults. Children from 6 to
12 years completed the CVFES, which pictorially depicts 30 items comparable to
those on the PBS, and yields the same 10 subscales. The items on the CVFES
require children to choose which of three pictures most closely resembles their own
family. The 10 subscales of the PBS and CVFES assess environmental characteristics
of the family within three broad domains: the Personal Growth Domain consists of
types of family activities, interests, and values, and includes the Achievement

Orientation, Independence, Active-Recreational Orientation, Moral-Religious, and

54

Intellectual-Cultural subscales; the System Maintenance Domain represents the degree
to which structure, control, and rules govern family life and is composed of the
Control and Organization subscales; finally, the Relationship Domain characterizes
the importance and types of interpersonal relationships within the family and includes
the Expressiveness, Cohesion, and Conflict subscales. Moos and Moos (1986) report
internal consistencies ranging from .61 to .78 and two-month test-retest reliabilities
ranging from .68 to .86 for the PBS subscales. The authors’ findings also support
adequate construct and discrmininant validity of the subscales (Moos & Moos, 1986).
In their work investigating characteristics of families with chronically ill and
healthy children, Kroneberger and Thompson (1990) derived three higher order
dimensions characterizing family environments: the Supportive, Controlling, and
Conflicted factors. The Supportive factor represents "the degree of mutual
commitment and support for expression of feelings and for active participation in
social and recreational activities" (Thompson, et al., 1992a, p. 579) and is composed
of the sum of scaled scores from the Cohesion, Expressiveness, Active-Recreational
Orientation, Intellectual-Cultural Orientation, and Independence subscales (Chronbach
alpha = .81). The Controlling factor reflects "emphasis upon control, ethical and
religious values, achievement orientation, and a lack of independence" (Thompson et
al., 1992a, p. 579) and is the sum of the Control, Moral-Religious Emphasis, and
Achievement Orientation subscale scores, minus the score for the Independence
subscale (Chronbach alpha = .65). The Conflicted factor represents "high conflict,

poor organization, and a lack of mutual commitment and support" within the family

55

(Thompson et al., 1992a, p. 579) and is comprised of the Conflict score minus the
scores for the Cohesion and Organization scales (Chronbach alpha = .84).
Kronenberger and Thompson (1990) demonstrated the construct validity and
utility of these three higher order factors in their investigation of family environments
of chronically ill and healthy children. They found that chronically ill children with
behavior problems came from more conflicted and less supportive families. More
specifically, the Conflicted factor was positively related to externalizing behavior
problems and negatively related to sociability. The Supportive factor was negatively
related to Internalizing behavior problems and positively associated with sociability.
These investigators also replicated the three factors in a sample of healthy children.
Additional studies have linked the three factors to child psychosocial adjustment. For
example, Thompson, Lampron, Johnson & Eckstein (1990) found that in a sample of
children with poor academic performance, children with greater behavior problems
(especially internalizing behaviors) had less supportive and more conflicted families.
In addition, in a sample of children with myelodysplasia, the Supportive and
Conflicted dimensions were related to internalizing and externalizing behavior
problems, respectively (Thompson, Kronenberger, Johnson, & Whiting, 1989).
Based on Moos and Moos’ (1986) construct of the family environment profile,
family members’ individual scores for each of the three factors (hereafter referred to
as support, control, and conflict) were averaged into composite family scores in the
present study. This approach was consistent with the view of the family as a system,

and reflected the transactional nature of family members’ perceptions and behaviors.

56

It also facilitated the examination of the relationship between the family climate and
child psychosocial outcomes.

Parental Self-Worth: Parents’ feelings of self-competence was assessed with
the Self-Perception Profile for Adults (Messer & Harter, 1986). This 50—item
questionnaire taps the following twelve domains: intelligence, job competence,
athletic competence, physical appearance, sociability, close friendship, intimate
relationships, morality, sense of humor, nurturance, household management, adequacy
as a provider, and global self-worth. This questionnaire has a similar format to the
Self-Perception Profiles for Children and Adolescents (see below). Messer and
Harter (1986) report internal consistency reliabilities ranging from .63 to .92 for two
different samples of adults including full-time working men and women, part-time
working women, and homemakers. The adequate provider scale was found to be
unreliable in samples of homemakers and part-time working women.

Impact of Stature and Coping Strategies: The impact of stature on the
parents and their coping strategies were also assessed as additional mediational
processes to adequate child adjustment. The Semi-Structured Interview detailed below

provided the data for these variables.

Child Mediational Processes
Self-Worth: Harter’s Self-Perception Profile for Children (Harter, 1982) and
Self-Perception Profile for Adolescents (Harter, 1988) were used to assess subject’s

self-perceptions of their own competencies in a number of different domains:

57

academic, social, athletic, physical appearance, and behavioral conduct. The
adolescent profile also includes three additional scales which were not used in this
study: job competence, close friendship, and romantic appeal. Both child and
adolescent forms also include a global self—worth scale. The children’s form includes
36 items, while the adolescent form contains 45. Each item depicts two contrasting
statements, from which children choose the one they are most like (e.g. , "Some kids
are happy with their height and weight BUT Other kids wish their height or weight
were different. "). Second, they decide if the statement is " really true" or "sort of
true" for them. The alpha reliabilities of the scale for children range from .73 to .87
(Harter, 1982; 1983) and for adolescents they range from .85 to .95 (Harter, 1988).
For the Self-Perception Profile for Children, Harter (1983) reports good test-retest
reliabilities for samples retested at three month and nine month intervals and adequate
convergent and construct validity.

Particularly relevant to this study is the finding that in a sample of 6th and 7th
graders, physical appearance was the domain most highly correlated with global self-
worth. Also of note were moderate relations among the social acceptance, athletic
competence, and physical appearance domains. Harter (1983) speculates that athletic
ability and physical attractiveness lead to greater popularity and acceptance among
peers.

Of special interest to this study is the degree to which subjects value physical
appearance. In order to assess the degree to which physical appearance is valued (or

devalued), subjects completed an importance rating for this domain. Importance

58
ratings are included at the end of the Self-Perception Profile for Children and

Adolescents. Items on the Importance Scale are structured similarly to those on the
Self-Perception Profiles. First, subjects choose which of two statements is most like
them. Second, they indicate whether this is "sort of true" or "really true" for them
(e.g., "Some kids think it’s important to be good looking in order to feel good about
themselves BUT Other kids don’t think that’s very important at all").

Impact of Stature and Coping Strategies: The impact of stature on the
children and their coping strategies were also assessed as additional mediational
processes to adequate adjustment. The Semi-Structured Interview detailed below

provided the data for these measures (see Appendices G and H).

Child Adjustment

Child adjustment was assessed with a parent-report measure, The Child
Behavior Checklist (CBCL-Achenbach & Edelbrock, 1983), one of the most widely
used measures for assessing children’s social competence and behavior problems. Of
particular interest to this study were the areas of behavioral, social, and academic
(scholastic) competence. First, parents or parent-figures report on the degree of their
child’s involvement and success in social activities and relationships, and academic
subjects. Second, parents complete a 113-item checklist by indicating the degree to
which their child has demonstrated the described behavior during the previous 6
months, from 0 (indicating that the item is not true of the child) to 2 (indicating that

the item is very true or often true of the child). The Child Behavior Profile is scored

59

from the CBCL and consists of three competence scales (activities, social, and school)
and eight behavior problem scales derived from factor analysis (withdrawn, somatic
complaints, anxious/depressed, social problems, thought problems, attention
problems, delinquent behavior, and aggressive behavior). In addition, the behavior
problem scales are divided into two broad-band factors labeled " internalizing " and
"externalizing ". The internalizing category includes: withdrawn, somatic complaints,
and anxious/depressed behaviors. The externalizing category consists of delinquent
and aggressive behaviors. Normalized T-scores, based on populations of nonclinical
samples, are available for the competence scales, behavior problem scales, and the
broad-band factors aVI =50, SD =10). Discrirninative validity is demonstrated by
significant differences on all social competence and behavior problem scores between
clinical and nonclinical samples. Median test-retest reliability is .89 and interparent
correlations for total behavior problems in a sample of 4-16 year-old children was .64
(Achenbach & Edelbrock, 1983). Construct validity is also reportedly high
(Achenbach, 1978; Achenbach & Edelbrock, 1979).

In this sample, mothers’ and fathers’ CBCL scores were strongly and
significantly related. Pearson correlations between parents’ scores ranged from r= .37
to r=.84 (all with p’s< .01, based on 47 or 48 pairs), with a mean of r=.63.
Interparent correlations for the internalizing and externalizing broad band factors were
r(48)=.66, p< .001 and r(48)=.78, p< .001, respectively, and for total behavior
problems was r(48)= .78, p < .001. Therefore, when both parents’ scores were

available, they were averaged into a composite score for each scale.

Semi-Structured Interview

Both parents and children participated in an individual semi-structured
interview (see Appendices G and H). The interview was developed for this study in
order to explore the impact of stature on subjects’ development, personality, coping
strategies, self-concept, and overall competence. All interviews were audio- or video-
taped and tapes were coded by reading the interviewer’s abbreviated transcript notes
while simultaneously watching and/or listening to the tapes.

Interview Coding Scheme

1) Parent and Child Family History of SS: Parent and child interviews were
coded for the presence or absence of a perceived family history of short stature. This
was based on the individual’s subjective perceptions of height, and not on a clinical
diagnosis or height estimate. The perceived presence of a family history of SS was
also coded for proximity to the individual (e.g. , parent, sibling, grandparent).

2) Coping Strategies: Avoidance and approach coping strategies were coded
for each parent and child interview. Avoidance coping included: distracting and
avoiding, ignoring, emoting, etc. Approach coping included: problem-solving,
seeking support, cognitive decision making, confrontion of an individual or situation,
etc. See Appendices I and J, the "Coping Coding Manual" and sample "Coding
Sheet," for a more detailed description of the coping categories and examples of
strategies. Proportion scores based on each category of coping response divided by
the total number of coping responses were calculated for each subject. Because there

were only two categories of coping, the proportion scores were somewhat redundant.

61

Therefore, results will be discussed in terms of approach coping.

3) Mt of Stature on Adjustment: After reviewing a subset of interviews,
it became apparent that stature could have both a positive and negative impact on
subjects’ lives. In order to assess the unique contributions of each of these
dimensions, two global assessments of the positive and negative impact of stature on
parents’ and children’s adjustment and life experiences were coded. Positive and
Negative Impact scores ranged from 0 (no positive/ negative impact) to 3 (strongly
positive/ negative impact), and were assigned after coders reviewed the subject’s entire

interview.

Inter-rater Reliability

The first step in coding the semi-structured interviews consisted of identifying
coping strategies. The second step involved classifying each strategy as either
Approach or Avoidance coping. Finally, coders assigned a Negative and Positive
Impact of Stature score after reviewing each interview in its entirety. A clinical
psychology graduate student served as the primary coder and an undergraduate senior
psychology major, without knowledge of subjects’ group membership, served as a
secondary coder. The secondary coder assisted in establishing and maintaining
reliability, and once reliability was sustained, independently coded a subset of
interviews. Training for coding coping strategies first involved reviewing, discussing,
and understanding the coding manual, categories, and behavioral examples of the

categories. Second, the coders reviewed, discussed and coded together a subset of

62

training interviews. Coders then independently coded a subset of training interviews
which were followed by discussion and resolution of differences. As suggested by
Gelfand and Hartman (1984), acceptable levels of reliability were considered at least
.70 for coping strategies and coping categories, and an r of at least .60 for Negative
and Positive Impact scores. Once these levels of reliability were maintained, coders
independently coded interviews. The primary coder coded approximately five times
as many interviews as the secondary coder. Rater drift was prevented by weekly
accuracy checks in which the secondary coder coded about every fourth interview of
the primary coder. Discrepancies in coding were settled through discussion. After
coping strategies were identified, those which both coders agreed upon (after
resolving differences) were rated as either Approach or Avoidance coping.

Reliability for identifying coping strategies was calculated by the following
formula suggested by Hakim-Larson and Hobart (1987) for segmenting speech units:
number of perfect agreements/one-half the sum of Rater A’s total responses plus
Rater B’s total responses. Inter—rater agreement on 24% of all the interviews was
.70. Reliability for coping categories (perfect agreement/total units) was .96. The
Pearson correlation coefficient between raters’ Negative Impact scores was

r(39)=.74, p< .001, and for the Positive Impact scores was r(39)=.60, p< .001.

Figure 2. Variables and Measures

63

 

VARIABLE

Diagnostic/Demographic Parameters

MEASURE

 

Diagnosis Child and Family Information
SES Questionnaire/Duncan TSEI2
Family Mediational Processes

Family Support, Conflict, Control
Parental Self-worth
Parental Coping Styles

Parental Impact of Own Stature

Family Environment Scale
Adult Self-Perception Profile
Semi-Structured Interview

Semi-Structured Interview

 

Child Mediational Processes

Self-worth

Coping Styles

Impact of Stature

Self-Perception Profile for Children or
Adolescents
Semi-Structured Interview

Semi-Structured Interview

 

 

Child Adj ustrnent
Social Competence
Behavior Problems

Academic Competence

 

Child Behavior Checklist (CBCL)
CBCL

CBCL

 

 

CHAPTER 4
Results

Statistical significance testing has been an area of considerable controversy,
especially within the past decade. More recently, there has been a growing body of
literature which criticizes the reliance of social science on significance testing, and
suggests alternative methods for determining the significance or importance of
research findings (see Carver, 1993; Judd, McClelland, & Culhane, 1995; Shaver,
1993; and Thompson, 1993). Kraemer and Thiemann (1988) emphasize that
"specification of the critical effect size and the required power. . .must be realistic, not
idealistic," (p.28). Similarly, Judd et al. (1995) suggest that "there is nothing sacred
about an alpha level arbitrarily set at .05. When the sample size is small and
constrained, an increase in power at somewhat greater risk of Type I error may be
worthwhile. This is often true in applied research," (p. 445). These researchers also
suggest that effect sizes, rather than levels of significance, be the focus of attention
(Carver, 1993). Judd et al. (1995) add that even small effect sizes may be of "both
theoretical and practical importance, " (p. 43 8).

The data analyses of this study were guided by these arguments. Because the
sample size was relatively small, it was deemed appropriate to increase power by
setting the alpha level at .10. While this increased the chance of Type I error, the
risks associated with it were judged to be less than those of Type II error. This
decision was based partly in the fact that the body of research on SS and its impact on

children and their families is quite limited. In addition, identifying areas of concern

65

has widespread implications for clinical intervention with children with SS and their

families.

flypptheses 1 apd 2: Group Differerm

A series of one-way analyses of variance (AN OVA) was run in order to test
the hypothesis that children and adolescents with SS would be rated by their parents
as having more psychosocial and behavioral problems than children with normal
stature (NS). The hypothesis was partially supported by the data (see Table 1). In
general, children with SS have higher scores on all of the behavior problem scales
than children with NS. These group differences are statistically significant for social
problems, internalizing behavior problems, and total behavior problems, with the SS
group exhibiting greater difficulties. In addition, as compared to children with NS,
children with SS are rated as having significantly lower overall competence; this
includes less involvement in extracurricular activities, having fewer close friends, and
less frequent contact with the friends that they do have. No correction for multiple
comparisons was made in these analyses, because the present study is concerned with
results that are clinically significant. While this approach risked inflating Type I
errors, the probability of this occuring was decreased by the small sample size and

low power. Nevertheless, these results need to be interpreted with some caution.

66

 

 

 

Table 1.
Group Comparisons for the Child Behavior Checklist‘
Short Stature Normal Stature
n=33

SCALE Mean SD Mean SD
Total Social Competence 45.92 6.90 53.88T‘l' 9.19
Activities 48.00 5.37 5039* 4.86

Social 43 .45 7.25 49.80H' 6. 14

School2 47.73 7.85 49.42 6.56

Social Problems 55.91 6.10 52.081L 3.68
Thought Problems 54.62 6.69 52.48 3.75
Attention Problems 55.91 8.68 53.56 5.83
Internalizing Behavior Probs. 51.35 10.00 45.94** 9.73
Social Withdrawal 53.52 6.22 51.95 3.39
Somatic Complaints 56.17 7.02 54.97 5.61
Anxious Depressed 54.82 7.45 52.70 4.28
Externalizing Behavior Probs. 49.77 10.29 46.33 10.01
Aggressive Behavior 54.41 7.23 53.05 6.05
Delinquent Behavior 53.98 6.17 52.55 4.63
Total Behavior Problems 51.35 10.54 44.77** 11.19

 

‘Composite T-scores averaged for mothers and fathers when both available.

2n=32 for the short stature group on this scale.

*p< .10
*"‘p< .05
’rp< .01
TTp< .001

67

Another series of one-way analyses of variance was run to test the hypothesis
that children with 88 would have lower self-competence than children with NS (see
Table 2). On all but one of the Self-Perception Profile scales, children with SS rated
themselves as having lower competence, with significant differences between groups
for global self-worth, athletic competence, and physical appearance. Thus, the
hypothesis was partially supported by the data. Of note is the fact that children with
SS rated themselves as having somewhat more socially appropriate behavior than
children with NS, although this difference was not statistically significant. Similar to
the analyses above, these results need to be interpreted carefully as no correction was

made for multiple comparisons.

 

 

 

 

 

Table 2.
Group Comparisgs for me Self-Perception Profile
Short Stature Normal Stature
n=32 n=33
SCALE Mean SD Mean SD
Global Self-Worth 3.15 .61 3.46b .57
Athletic Competence 2.74 .86 3.15b .57
Behavioral Conduct 3.14 .58 2.98 .70
Physical Appearance 2.76 .80 3.06a .56
Scholastic Competence 3.08 .74 3.16 .66
Social Acceptance 2.93 .64 3.19 .68
‘p< .10

bp< .05

68

Further (post-hoe) analyses were performed to assess differences between the
two groups in coping, the impact of height, and selfldescriptions of height. A two-
tailed unpaired t-test was conducted to test for group differences in coping strategies.
There was no difference between children with SS and NS in their proportional use of
coping strategies (t=.63, df= 39, p=.53). Thus, children with SS were no more
likely than children of NS to use approach or avoidant coping strategies. With regard
to stature, there was no significant difference between the two groups in their positive
impact scores (t=.19, df =58, p=.85). However, compared to children of NS,
children with SS received significantly higher negative impact scores (t=7.02,
df= 50.85, p < .001) and more frequently described themselves as below average in

height (t=6.47, df=44.88, p< .001).

Hypothesis 3: Gender Differences

The hypothesis that boys with SS would demonstrate greater psychosocial and
behavior problems than girls with SS and children with N8 was assessed in two ways.
First, a 2 X 2 analysis of variance (AN OVA) was run to examine gender by stature
interaction effects and gender main effects. This initial step was performed because
of a potential confound in comparing boys with SS and girls with SS to children with
NS. Any observed differences in this comparison could be due to general gender
differences, rather than to differences specific to children with SS. This preliminary
analysis revealed no significant gender by stature interaction effects. Hence, a series

of one-way analyses of variance followed, comparing the three groups (SS boys, SS

69

girls, and NS children) on the outcome variables (all of the CBCL scales and factors,
and the Self-Perception Profile scales). As demonstrated by Tables 3, 4, and 5, the
hypothesis is only partly supported by the data.

Tables 3, 4 and 5 display only the analyses resulting in significant F-values
(p < .10). For the CBCL behavior scales (see Table 3), significant between-group
differences (p < .05) were found for Total Behavior Problems and Social Problems.
Boys with SS had significantly more behavior problems than children with NS,
however girls with SS did not differ significantly from either group. Girls with SS
had the most internalizing behavior problems, but between-group differences did not
reach the .05 criterion on this factor. Boys with SS also demonstrated more
significant social problems than children with NS, while girls with SS demonstrated
levels of social problems between, but not significantly different from, the other two
groups.

On the competence scales of the CBCL, significant F-values were found for
activities and social competence (see Table 4). Girls with SS participated in
significantly fewer extracurricular activities than boys with SS and children with NS,
who did not differ significantly from each other on this scale. Boys and girls with SS
had similar levels of social competence, which were significantly lower than that of

children with NS.

Table 3.

70

.O_ne-Wav Anplvsis of Variance (ANOVA) for Stature X Gender Groups and CBCL

Behavior Problem Scales

 

CBCL Scales

 

Total Behavior

Internalizing

 

Social Problems*

 

Problems* Behavior Problems
_pGrou N M. i). M. _S_D M £2
SS Boys 23 51.33 9.54 51.30 8.49 56.33 6.35
SS Girls 10 51.40 13.14 51.45 13.38 54.95 5.66
NS 33 44.77 11.19 45.94 9.73 52.08 3.68
Children
F 2.97a 2.443 5.00b

 

*SS Boys are significantly different from NS Children at the .05 level, while SS Girls
do not differ significantly from the other two groups.

ap<.10
bp<.01

71
Table 4.

One-Way Analysis of Variance (ANOVA) for Stature X Gender Groups and CBCL

 

Competence Scales

 

CBCL Scales

 

 

Activities* Social”
_nGrou N M. SD M _82
SS Boys 23 49.20 4.41 43.13 7.08
SS Girls 10 45.25 6.55 44.20 7 .98
NS 33 50.39 4.86 49.80 6.14
Children
F 4.07b 7.36c

 

*SS Girls are significantly different from SS Boys and NS Children at the .05 level,
while SS Boys and NS Children do not differ significantly from each other.

**NS Children are significantly different from SS Boys and SS Girls at the .05 level,
while SS Boys and SS Girls do not differ significantly from each other.

ap<.10
bp<.05
cp<.01

72
Table 5.

One-Way Analysis of Variance (AN OVA) for Stature X Gender Groups and Self-
Perception Scales

 

 

Self-Perception Scales

 

Athletic Comp_etence Physical Appearance*

 

_nGrou M M _S_D M ill
SS Boys 23 2.78 .77 2.88 .87
SS Girls 10 2.65 1.06 2.51 .59
NS 33 3.15 .57 3.06 .56
Children

F 2.65“ 2.49“

 

*SS Girls are significantly different from NS Children at the .05 level, while SS boys
do not differ significantly from the other two groups.

ap<.10

73

On the Self-Perception Profile, significant F-values were found for the athletic
competence and physical appearance scales (see Table 5). While group differences on
the athletic competence scale did not reach significance at the p < .05 level, girls with
SS rated themselves the lowest, children with NS the highest, and boys with SS rated
themselves between the two. On the physical appearance scale, girls with SS rated
themselves significantly lower than children with NS, while boys with SS rated
themselves between the two groups and did not differ significantly from either of

them.

Hypothesis 4: Age Differences

The hypothesis that younger children (under 12 years) with SS would
demonstrate greater self-competence, but also greater psychosocial and behavior
problems than older children and adolescents with SS (12 years and older), was only
partially supported by the data. A series of one-way analyses of variance assessed
group differences on the child outcome measures. On the Self-Perception Profile for
Children and Adolescents, the younger group rated themselves significantly higher on
athletic competence (F[1,30]15.55, p< .001), physical appearance (F[,30]4.73,
p< .05), behavioral conduct (F[1,30]=3.37, p< .10), and global self-worth
(F[1,30] =3.25, p< .10). There were no significant differences between the groups
on the scholastic competence or social acceptance scales of this profile. In addition,
contrary to the hypothesis, there were no significant age group differences on any of

the competence and behavior problem scales and factors of the CBCL. A post-hoe

74

two—tailed unpaired t-test revealed no significant difference between the age groups in

their use of approach or avoidant coping strategies.

Hypothesis 5: Family Histog of SS

It was predicted that children who have either a perceived or diagnosed family
history of SS would demonstrate better psychosocial adjustment than those without a
perceived or diagnosed family history of SS. This hypothesis was tested in two sets
of analyses, examining perceptions of familial short stature (FSS) separate from
diagnosed FSS. The semi-structured interview provided data regarding children’s
perceptions of family members’ stature. Of the 30 children with SS who participated
in the interview, only 6 of them did not perceive a family member (e.g., parent,
sibling, grandparent, etc.) as below average in height. A series of one-way analyses
of variance provided comparisons between children with SS with and without a
perceived family history of SS on the outcome measures (CBCL and Self-Perception
Profile scales). N 0 significant group differences were found except for one, which
was in the opposite direction to that which was predicted. On the Self-Perception
Profile, children with SS who reported a perceived family history of SS rated
themselves as less satisfied with their physical appearance than those without a
perceived family history of SS (F[l,27]=5.20, p< .05).

In order to test the second half of Hypothesis 4, a series of one-way analyses
of variance was run to assess differences on the outcome measures between the 2

diagnostic groups of children with SS who did not have a family history of SS (CD

75
and GHD) and the 2 diagnostic groups that m (FSS and CD/FSS). Only one

between-group difference was found. Children with a family history of SS were rated
significantly higher on the CBCL scale of social competence than those without FSS
(F[1,30] =7.12, p< .05). Comparable results were found when the one-way

AN OVA’s were run comparing all four diagnostic groups on the outcome measures.
Children with FSS had the highest social competence scores, whereas children with
CD had the lowest (F[3,28] =2.94, p=.05). The difference between these two
groups was significant at the p < .05 level. Children with GHD had the second
lowest scores and children with CD/FSS had the second highest scores on the social
competence scale, but no other groups were significantly different from one another.
Therefore, examining the 4 diagnostic groups separately did not mask the effect, and

it provided more specific data regarding group differences.

Hypothesis 6: Devaluing Physical Appearance

One-way analyses of variance were also used to test the hypothesis that
children with SS who devalued physical appearance would have greater self-esteem
and fewer internalizing behavior problems than children with SS who felt that physical
appearance was more important. The Harter Self-Perception Profile Importance
Rating Scale provided the measure of children’s value of physical appearance. The
children with SS were divided into a devaluing group (n=21) and a valuing group
(n=11) using a median split on the importance of physical appearance rating

(devalue <2.75 <value). These two groups were compared in a series of one-way

76
analyses of variance on the Self-Perception Profile Scales, the CBCL internalizing

factor, and the CBCL narrow-band scales which comprise the internalizing factor
(anxious/depressed, somatic complaints, and withdrawal). Post-hoe analyses also
compared the groups on the CBCL parent ratings of activities, social, and school

competence.

As predicted, compared to children with SS who valued physical appearance,
those who devalued it rated themselves as having higher: school competence
(F[1,30]=4.43, p< .05), athletic competence (F[l,30]=3.44, p< .10), and global
self-worth (F[1,30] =3.20, p< .10). In addition, children who devalued physical
appearance rated themselves as significantly more satisfied with the way they look
(F[1,30] =8.02, p< .01). Comparisons of the two groups on the CBCL behavior
scales, internalizing factor, and competence scales yielded no significant between-
group differences, except for one which was opposite to that which was expected.
Children who devalued physical appearance were rated as having more somatic
complaints than children who valued it (F[1,30] =3.40, p< .10). Thus, hypothesis 5
was only partially supported by the data.

Additional post-hoe analyses revealed that there was a strong correlation
between how children felt about their physical appearance and their global self-worth
(r[65] = .64, p< .001). This relationship was more robust for children with SS
(r[32]=.84, p< .001) than for children with NS (r[33]=.32, p< .10). However,
there was no difference between the groups in the degree of importance they placed

on their physical appearance (t=0, df =62, p=1).

77
Hypotheses 7. 8. 9. afll 10 : Family Factors in Child Outcomes

Pearson correlations assessed relationships between family members on each of
the family environment factors. None of the intra-family correlations were
statistically significant for the support factor, while correlations for control and
conflict ranged from .31 to .63 and were all significant at at least the p< .05 level.
Associations between parents were the strongest, and those between each parent and
child were comparable. Pearson correlations between the composite (averaged)
factors for this sample of 66 families were as follows: support and control (r=-. 16,
p=.20), support and conflict (r=-.68, p< .001), and control and conflict (r=-.20,
p= .12). Thus, only family support and conflict were significantly correlated.

Two-tailed unpaired t-tests were used to assess whether families of children
with SS were more controlling than families of children with NS. While families of
children with SS were slightly more controlling than families of children with NS, this
difference was not statistically significant (t=.56, df =64, p=.58). Thus, Hypothesis
6 was not supported by the data. Post-hoe analyses on the two other family factors
revealed that compared to families of children with NS, families with SS were viewed
as somewhat less supportive (t=1.64, df =64, p=.11), but no different in terms of
family conflict (t=-.28, df=64, p=.78).

Hypothesis 8 predicted that families high in support and low in both control
and conflict would have children with higher self-esteem and psychosocial adjustment
than families with other combinations of these family environment factors. First,

Pearson correlations assessed the relationships between the family environment factors

78

and child outcomes (Self-Perception Profile; CBCL competence scales, behavior
problem scales and factors). As illustrated in Table 6, family support is the factor
most strongly related to child adjustment, whereas family conflict is the least.
Additionally, family support is the only factor that correlates with the scales of the
Self-Perception Profile. Global self-worth, school competence, and social acceptance
are all moderately and positively related to family support. Family support also is
correlated with the most scales on the Child Behavior Checklist. It is moderately and
negatively related to total behavior problems, withdrawal, anxious/depressed, social
problems, externalizing behavior, and aggression. On the other hand, family support
is moderately and positively related to total competence and social competence.
Family control is positively associated with total behavior problems, social problems,
attention problems, externalizing, and delinquent behavior. Family conflict is
moderately and positively correlated with thought problems, externalizing behavior,
and aggression. In sum, Hypothesis 8 is generally supported by the data derived from
the Pearson correlations. Family support was associated with better child
psychosocial adjustment, whereas family control and conflict were associated with
poorer child adjustment. Family support proved to be most highly related to child
adjustment, while family conflict was the least and family control was between the

two.

Table 6.

79

Pearson Correlations Between the Family Environment Factors and

Child Outcome Measures

 

Thild Measures

Family Environment mars

 

Self-Perception Profile
Global Self-Worth

School Competence
Social Acceptance
Athletic Competence
Physical Appearance
Behavioral Conduct

Child Behavior Checklist

Total Problems
Internalizing Behavior
Withdrawal
Somatic Complaints
Anxious/Depressed
Social Problems
Attention Problems
Thought Problems

Externalizing Behavior
Delinquent Behavior

Aggression

Total Competence Index

Activities
Social
School

Family Support Family Control

.33c
.31b
.27"
.08
.15
.14

-.24a
-.20
-.23‘
-.09
-.23’
-.23‘I
-.15
-.09
-.31b
-.16
«.37c
.27"
.04
.35c
.15

-.10
-.04

.04
-.07
-.01
-.05

.23a
.15
.15
.09
.19
.23a
.20‘
.08
.22ll
.24'
.14
-.03
.02
-. 10
-.03

Family Conflict

-.14
-.18
—.04

.00
-.19
-.19

.18
.09
.12
.10
.14
.16
.16
.23‘
.30"

.33c
-.09

-.08
-.11

 

*Note: n=65 for Self-Perception Profile corr’s.; n=66 for CBCL corr’s.

‘p<.10
hp<.05
cp<.01

8O
Hypothesis 8 was further assessed in a second set of analyses. The three

family environment factors (support, control, conflict) were divided into high and low
groups based on median splits. Next, a series of one-way analyses of variance
compared families who were high in support and low in both control and conflict
(n= 14) to all other families (n=52) on the child outcome measures (Self-Perception
Profile; CBCL competence scales, behavior problem scales and factors). These
analyses yielded few statistically significant between-group differences. On the Self-
Perception Profile, children from families high in support and low in control and
conflict rated themselves as more satisfied with their physical appearance than
children from the other families, but this difference did not reach significance at the
.10 level (F[1,63]=2.63, p=.11). On the CBCL, children from the high support,
low conflict and control group were rated as having fewer externalizing behavior
problems (F[1,64] =2.77, p=.10) and fewer delinquent behaviors (PH, 64] =4.69,
p < .05). No other group comparisons resulted in significant differences, although
most were in the direction predicted by the hypothesis. Thus, the two sets of analyses
provided limited support for the hypothesized relationships between family support,
control, and conflict on the one hand, and child psychosocial adjustment on the other.
The data were only partly supportive of Hypothesis 9, which predicted that
parents’ use of coping strategies would be positively related to children’s coping
strategies. Pearson correlations indicated no relationship between mothers’ and
children’s coping, and revealed a moderate positive correlation between fathers’ and

children’s coping (r[30] = .33, p< .10). To look more closely at the levels of

81

associations between parents’ and children’s coping, the correlations were run
separately for boys and girls. For boys’ coping, the correlation was r(24)= .35,

p< .10 with fathers, and r(32)= .04, p= .84 with mothers. The correlation between
girls’ and fathers’ coping was r(6)=.41, p=.42, and with mothers’ was r(7)=.53,
p= .22. Based on the size of the correlation coefficient for girls’ and fathers’ coping,
the level of association appears to be comparable to that of boys and fathers. This
suggests that the lack of significance for girls was due to the small sample size. On
the other hand, while there was no association between boys’ and mothers’ coping,
there is a possible association between girls’ and mothers’. Of interest is the fact
that mothers’ and fathers’ coping were more strongly related (r[36] =.34, p< .05)
than parents’ and children’s coping.

Similarly, the prediction that children’s approach coping would be associated
with better child psychosocial adjustment than avoidance coping was generally
unsupported by the data. To test Hypothesis 10, Pearson correlations were run
between children’s coping style and the outcome measures (Self-Perception Profile
scales, CBCL competence scales, and behavior problem scales and factors). These
analyses resulted in only two statistically significant correlations at the .10 level.
There was a small negative association between approach coping and withdrawal
(r[41] = -.27, p < .10) and a small positive relation between approach coping and
somatic complaints (r[41] = .26, p < .10). The latter finding is contrary to that which

was predicted.

82
Hyp_othesis 11: The Stress and Coping Model

The predicted relationships among the variables in the Stress and Coping
Model (see Figure 1) were examined first with Pearson correlations and then assessed
with a series of multiple regression analyses. Pearson correlations between the
outcome and predictor variables are displayed in Tables 7, 8, and 9. Among the
diagnostic/demographic parameters, child social competence was positively correlated
with stature and SES (see Table 7). By contrast, behavior problems were negatively
related to stature and SES. Academic competence was significantly and positively
associated with SES.

Of the family mediational variables, family support and mothers’ negative
impact of stature had moderate positive associations with social competence (see
Table 8). On the other hand, mothers’ (approach) coping and fathers’ negative
impact of stature were both negatively related to social competence. Child behavior
problems were moderately and positively related to family control and father’s
coping, and moderately negatively associated with family support and father’s global
self—worth. Academic competence correlated significantly with both parents’ global

self-worth.

83
Table 7.

mmon Correlation Coefficipnts for the Diagnostic/Demographic and Child

Adjustment Variables of th_e Stress and Coping Model

 

 

 

 

OUTCOME VARIABLES
PREDICTOR VARIABLES Social Behavior Academic
Competence Problems Competence
Stature .43d -.29h . 12
Gender -.04 .18 -.10
Age .02 -.08 .13
SES .27b -.33c .37c

 

Note: p=66 for Social Competence and Behavior Problems; p=65 for Academic
Competence

ap<.10
bp<.05
cp<.01
dp<.001

84
Table 8.

Pearson Correlation Coefficients for the Family Mediational and Child Adjustment

Variables of the Stress and Coping Model

 

 

 

 

OUTCOME VARIABLES
PREDICTOR VARIABLES Social Behavior Academic
Competence Problems Competence
Family Support 35‘ -.24' .15
(66) (66) (65)
Family Conflict -.08 .18 -. ll
(66) (66) (65)
Family Control -.10 .23" -.03
(66) (66) (65)
Mothers’ Global Self-Worth .18 -.14 .29b
(66) (66) (65)
Fathers’ Global Self-Worth .04 -.42c .25'
(49) (49) (49)
Mothers’ Coping -.29" .21 -.06
(55) (55) (54)
Fathers’ Coping -.21 .37" -.13
(40) (40) (39)
Mothers’ Neg. Impact .25‘ .07 -.21
(59) (S9) (58)
Fathers’ Neg. Impact -.28‘ -.02 -.05
(44) (44) (43)
Mothers’ Pos. Impact .12 -.08 .14
(59) (59) (58)
Fathers’ Pos. Impact .19 -.23 .09
(44) (44) (43)
‘p< .10
bp< .05
‘p< .01

dp<.001

85
Table 9.

Pearson Correlation Coefficients for th_e Child Mediational and Child Adjustment

Variables of the Stress and Coping Model

 

 

 

OUTCOME VARIABLES
PREDICTOR VARIABLES Social Behavior Academic
Competence Problems Competence
Children’s Global Self-Worth .23a .02 .01
(65) (65) (64)
Children’s Coping .18 .11 .06
(41) (41) (41)
Children’s Neg. Impact -.45‘1 .11 -.04
(60) (60) (59)
Children’s Pos. Impact .14 .01 .17
(60) (60) (59)

 

ap<.10
bp<.05
°p<.01
dp<.001

Overall, the child mediational variables were not strongly associated with child
adjustment (see Table 9). Social competence was positively related to global self-
worth, and negatively related to children’s negative impact of height. Behavior
problems and academic competence did not correlate significantly with any of the
child mediational variables.

Of the 60 families that participated in the semi-structured interview, there were

only 28 in which all three family members (child, mother, and father) gave responses

86

which could be coded as coping strategies. Therefore, the multiple regression
analyses testing the Stress and Coping Model were run on this subset of 28 families.
This sample was composed of 23 boys and 5 girls, and 19 children with SS and 9
with NS. The predictor variables from each set were regressed onto the outcome
variables in a hierarchical procedure, as determined a priori by the model. More
specifically, variables within the diagnostic/demographic parameters, then the family
mediational processes, and finally the child mediational processes were regressed onto
the child psychosocial adjustment variables as measured by the CBCL social
competence, total behavior problems, and school competence scales. The order of
entry of the predictors indicates the increment in child psychosocial adjustment
accounted for by the inclusion of family mediational processes and child mediational
processes beyond that attributed to the diagnostic/demographic parameters. The order
of entry within sets of the predictor variables was determined by a forward stepwise
procedure. First, the diagnosis parameter (short stature/ normal stature) was entered,
followed by the demographic parameters of gender, age, and SES. The magnitude of
the variance accounted for by each demographic parameter established the order of
entry. Next, the family mediational processes (family support, control, and conflict;
parents’ self-esteem; parents’ coping styles; and parents’ impact of stature) were
allowed to enter the regression if they met the criteria for inclusion: accounting for
additional variance in the outcome variable significant at the .10 level. In sum, the
regression analyses were stepwise within sets of predictor variables and hierarchical

between sets of predictor variables.

87

Preliminary analyses involved regressing each set of predictor variables
independently onto the outcome variables using a forward stepwise procedure. These
results are depicted in Blocks 1 through 3 of Tables 10 and 11. Only those variables
which entered the model are present in the tables. Following the method of
Thompson, Gustafson, Hamlett, and Spock (1992), the standardized regression
coefficients (b) represent the relationship between each predictor variable and child
adjustment. The R2 change (squared semipartial correlation) depicts the increment of
variance accounted for by each predictor. The corresponding F indicates whether this
increment is significant. Finally, the cumulative R2 represents the total variance in
the outcome accounted for by the predictors in the model.

Table 10 illustrates the results from the regression analyses for total behavior
problems. Block 4 depicts the final step of the analyses in which all sets of the
predictors are entered into the model in a hierarchical fashion. Of the diagnosis and
demographic parameters, stature accounted for 12% of the variance in behavior
problems, and children with SS had greater behavior problems. However, once
block 2 was entered, stature was no longer significant. Family mediational processes
(specifically, fathers’ coping and fathers’ positive impact of stature) accounted for an
additional 4% and 3 % of the variance in behavior problems, respectively. Of note is
that fathers’ coping was positively related to behavior problems, while fathers’
positive impact of stature was negatively related to this outcome. None of the child
mediational variables were significant. Together the variables of the model predicted

46 % of the variance in total behavior problems. Because only the fathers’ predictor

88

variables entered the model from family mediational processes and there were more
boys than girls in the sample, the possibility existed of an interaction between child
gender and fathers’ predictors. Therefore, two multiple regression analyses were
performed in which child gender, father predictor (coping or positive impact of
stature), and the child gender X father predictor interaction were regressed onto total
behavior problems. Both of the interactions were nonsignificant. Thus, the
association between fathers’ predictors and total behavior problems was not moderated
by child gender.

None of the sets of variables significantly predicted any variance in child
academic competence. Thus, the model did not adequately predict the relationships
among the diagnostic/demographic parameters, family mediational and child

mediational processes, and child academic competence.

89
Table 10.

Summag of the Hierarchical Multiple Regression Scores for Total Behpvior Problems

 

 

 

 

Variables b3 R2 change I?" Qrmulative R2
Block 1

Stature -.34 .12 3.43° .12
Block 2

Fathers’ Coping .51 .26 9.08c .26
Fathers’ Pos. Imp. -.45 .20 9.35° .46
Block 3

Block 4

Stature -.34 .12 3.43c .12
Fathers’ Coping .44 .16 5.46‘1 .27
Fathers’ Pos. Imp. -.44 .19 8.47c .46

 

“Standardized regression coefficient.
"F test on R2 change.

‘p < . 10

4p < .05

6p < .01

fp < .001

Table 11.

Summary of th_e Hierarchical Multiple Regression Scores for Social Competence

 

 

Variables b“ R2 change F" Cumulative R2
floil

Stature .57 .33 12.69f .33
SES .34 .11 5.01d .44
m

Family Control -.46 .21 7.02d .21
Mothers’ GSW .34 .12 4.37‘1 .33
flick;

Child’s Neg. Impact -.51 .26 924° .26
BM

Stature .57 .33 12.69f .33
SES .33 .11 5.01d .44
Family Control -.35 .11 5.72d .55
Mothers’ GSW .29 .08 4.87‘1 .63
Child’s Coping .38 .12 10.31‘ .75

 

aStandardized regression coefficient.

"F test on R2 change.
cp< .10

dp< .05

cp< .01

fp< .001

91

The results of the multiple hierarchical regression analyses for social
competence are found in Table 11. The diagnostic and demographic parameters of
stature and SES accounted for 44% of the variance in social competence. Family
mediational processes (family control and mother’s global self-worth) and child
mediational processes (child’s negative impact of stature) accounted for an additional
19% and 12%, respectively. When all the variables entered the model, however, SES
was no longer significant. Altogether, the predictor variables of the stress and coping
model accounted for 75 % of the variance in child social competence. Because the
amount of variance accounted for was suspiciously high, a Durbin-Watson diagnostic
test of collinearity was run. Collinearity is the condition in which independent
variables are highly correlated, thus making it difficult to separate out their
independent effects. The Durbin-Watson statistic (2.32) was out of bounds, indicating
a problem of collinearity in the model between child coping and stature. Hence, post-
hoc analyses were performed in which alternative models were tested.

First, Block 4 of the multiple regression was run in which child coping was
allowed to enter the model first, followed by the remaining predictors, which were
forced into the model according to their order in the previous analysis. The resulting
R2 was .75 (F=12.91, p< .001), and the Durbin-Watson statistic (2.20) was out of
bounds, indicating a recurrent problem with collinearity. In a second analysis, all of
the predictors except child coping were entered in a forced entry according to the
original analysis. In the final step, child coping was allowed to enter the model.

This analysis resulted in an R2 of .75, and the Durbin—Watson statistic (2.32) was still

92

out of bounds. When child coping was removed from the model, the predictors
accounted for 63% of the variance in social competence, and the Durbin-Watson
statistic (1.98) was close to acceptable limits. The large change in the R2 associated
with the inclusion (or exclusion) of child coping in the model appeared spurious, and
due in part to collinearity. This was supported by the fact that there was no
association between child coping and social competence at the bivariate level

(r(28)= . 15, p=44). Hence, the contribution of child coping to the model remains
unclear.

A final set of post-hoe analyses was performed in which coping was removed
from the model altogether. The same procedures were followed as in the original
hierarchical multiple regression analyses. These analyses had a number of advantages
over those which included coping. First, they allowed the model to be run with a
larger number of subjects (n=66). Second, they offered a view of the model without
the problems of collinearity caused by coping. Tables 12, 13, and 14 illustrate the
results.

Table 12 depicts the results for total behavior problems as the outcome
variable. The diagnostic and demographic parameters of stature, SES, and age
accounted for 27% of the variance. Family conflict contributed an additional 5 % of
the variance in behavior problems. The child mediational variables failed to enter the
model. Altogether, the predictor variables accounted for 32% of the variance in child
behavior problems. Table 13 illustrates the results for academic competence as the

outcome. Only stature accounted for a significant amount of the variance (14%) in

93

academic competence, once all of the variables were entered in the model. For social
competence (see Table 14), 25 % of the variance was attributed to stature. Family
support, mothers’ positive impact of stature, and fathers’ negative impact of stature
scores accounted for an additional 24% of the variance. None of the child
mediational variables were significant. The diagnostic/demographic parameters and
family mediational processes accounted for a total of 49% of the variance in social

competence.

94
Table 12.

Summag of the Hierarchical Regression Scores for Total Behavior Problems:
Coping Removed from the Model

 

 

 

Variables ba R2 change F" Cumulative R2
Block 1

SES -.33 .11 806‘ .11
Stature -.27 .07 5.61(1 .18
Block 2

Fathers’ GSW -.30 .09 3.87c .09
Fathers’ Pos. Imp. -.25 .06 2.93c .15
Block 3

Block 4

Stature -.36 .13 5.91d .13
SES -.28 .08 3.71c .20
Age -.25 .06 3.17c .27
Family Conflict .26 .05 2.91c .32

 

“Standardized regression coefficient.
bF test on R2 change.

cp < . 10

dp < .05

ep < .01

fp < .001

95
Table 13.

Summary of th_e Hierarchical Multiple Regression Scores for Academic Compptence:

 

Coping Removed from the Model

 

Variables b3 R2 change F" Cumulative R2

 

Block 1
SES .37 .13 9.73“ .13

Block 4
Stature .37 . 14 6.56d . 14

 

“Standardized regression coefficient.
bF test on R2 change.

cp < . 10

dp < .05

“p < .01

fp < .001

Table 14.

96

Summm of the Hierarchical Multiple Regression Scores for Social Compatence:

 

Coping Removed from the Model

 

 

 

Variables b’ R2 change F" Cumulative R2
Mic;

Stature .43 .19 14.73f .19
SES .24 .06 4.79d .24
M

Family Support .52 .27 14.59f .27
Mothers’ Pos. Imp. .25 .06 3.53c .33
Fathers’ Neg. Imp. -.24 .06 3.40° .38
Family Conflict .27 .05 336° .43
Block 3

Child’s Neg. Impact -.44 .20 13.91f .20
ELOLRA

Stature .50 .25 13.02f .25
Family Support .38 .13 781‘ .37
Mothers’ Pos. Imp. .26 .06 4.31d .44
Fathers’ Neg. Imp. -.23 .05 3.72c .49

 

aStandardized regression coefficient.

bF test on R2 change.
=p< .10

dp< .05

=p< .01

Ep< .001

CHAPTER 5
DISCUSSION

Group Differences

The results of this study are generally consistent with a large body of research
that indicates poorer psychosocial and behavioral adjustment in children with SS as
compared to children with NS. In this sample, children with SS were rated by their
parents as having significantly more total behavior problems, internalizing behavior
problems, and social problems and significantly less social competence and
involvement in extracurricular activities than children with NS. In addition, as
compared to their peers of NS, children with SS rated themselves as having
significantly lower global self-worth, athletic competence, and satisfaction with their
physical appearance.

In spite of these results, there were fewer statistically significant group
differences in this sample than expected, based on previous investigations. For
example, children with SS have consistently been found to have greater externalizing
behavior problems and attention deficits (Abbott et al., 1982; Gold, 1978; Lewis et
al., 1986; Ryan et al., 1988; Siegel et al., 1982, 1986, 1990). In addition, failure to
find differences between the groups on parents’ ratings of academic/ scholastic
competence is inconsistent with a large body of literature indicating that children with
SS have specific learning disabilities which contribute to academic underachievement
(Siegel et al., 1982, 1986, 1990). The present findings parallel those of Sandberg,

Brook, and Campos, (1994) who found no differences between children with SS and

97

98

those with NS on the same measure used in this study, and Gordon et al. (1982;
1984), who found no differences on measures of academic achievement. Gordon and
his colleagues (1982; 1984) also reported greater somatic complaints, social
withdrawal, and schizoidal tendencies in the SS children-—differences not found in the
present study.

With regard to the self-perceptions of children with SS, the findings of
previous studies have been largely inconsistent. In the present study, children with
SS report lower global self-worth and less satisfaction with their physical appearance
than their counterparts with NS. These results support the theoretical discussions of
Crocker and Major (1989) regarding the impact of social stigma, and are consistent
with the results of Martel and Biller’s (1987) interview study of short young adult
males. These results are inconsistent, however, with the average or elevated self-
worth reported by children with SS in Siegel’s (1982) and Young-Hymans’ (1986;
1990) investigations. Further, these results challenge Clopper’s (1992) contention that
even in the face of dissatisfaction with one’s outward appearance, overall self-worth
can be high. In this sample of children, the relationship between global self-worth
and satisfaction with physical appearance was strong, and more so for short children
than those with NS.

Of interest is the fact that children with SS rated themselves as having more
socially appropriate behavior than children with NS. In addition, they felt equally as
competent in social relationships. These self-perceptions are somewhat discrepant

from parental reports of child behavior and social problems. Inflated self-perceptions

99

of children with SS in these areas may be the result of defensive responding (e.g. ,
denial or repression), similar to that reported by Zimet and his colleagues (1993) and
Mitchell et al. (1986). An additional explanation for differences in parent- and child-
reported behavior and social competence may be that children with SS have impaired
judgment with regards to their own behavior and its impact in social situations. This
explanation is supported by Young-Hyman’s (1986) study in which children with SS
had significant difficulty on a social problem-solving task, but rated themselves as
highly competent at it.

The failure to find more statistically significant between-group differences in
this study may be due in part to the small sample size. In addition, it may be
indicative of a recent trend in the study of SS in which less psychopathology is found
in individuals with SS than in the past (see Stabler & Underwood, 1994). Fewer
differences between populations of individuals with SS and those of normal height
may be a result of increased knowledge of and sensitivity to the needs and difficulties
of short persons. As a result, children with SS may be referred for treatment earlier
in their lives, and they may receive more comprehensive care than in the past.
Although participation in counseling or psychotherapy was not formally assessed in
the present study, 8 children with SS and their families acknowledged receiving this
assistance, due in large part to difficulties related to SS. By contrast, only 2 families
in the NS group acknowledged participation in therapy for behavior and adjustment
problems.

The group differences that were found in the present study are clinically

100

important and have implications for interventions with children with SS. In
particular, interventions with children with SS need to focus on increasing positive
feelings about themselves, especially their physical appearance, and involving them in
activities and athletics which are not contingent on size (e.g. , gymnastics, soccer,

wrestling, tennis).

Gender Differences

Overall, there were fewer differences between boys and girls with SS than
were predicted. Whereas boys with SS were expected to demonstrate poorer
psychosocial adjustment than pm girls with SS and children with NS, this hypothesis
was only partially supported by the data. In the areas that boys with SS demonstrated
significantly more difficulties than children of N S (total behavior problems and social
problems), girls with SS did not differ significantly from either group. Both boys and
girls with S8 had significantly lower social competence than children with N8 as rated
by their parents. In addition, girls with SS demonstrated more internalizing behavior
problems, less involvement in extra-curricular activities, and rated themselves lower
on athletic competence and physical appearance than the other two groups. Girls with
SS differed significantly from both groups in their participation in clubs, on teams, or
in social organizations.

In spite of greater social acceptance and desirability of a small physique in
females, these results suggest that clinical short stature impacts boys and girls in

similar ways. More importantly, there are areas in which girls with SS fare more

101

poorly than boys with SS. Yet ironically, girls are less likely to be referred for
treatment of SS (Clopper, 1992). One explanation for the higher than expected rate
of psychosocial problems in girls with SS could be that in order for them to be
referred for treatment, they or their parents must experience greater distress or
concern regarding their stature and its impact. Given this possibility together with
girls’ tendency to have more concerns about their physical appearance than boys
(Frazier & Lisonbee, 1950), it is not surprising that girls with SS were the least
satisfied with the way they look. In addition, as females have increasingly entered
traditionally male-dominated arenas (e. g. , competitive athletics, employment outside
the home, and politics) stature has potentially increased in importance for them. In
light of data suggesting that small females are regarded as more dependent and
helpless and less competent (Eisenberg et al., 1984), a more "average" stature might

facilitate females’ abilities to compete and succeed in these areas.

Age Differences

As anticipated, younger children with SS generally had greater feelings of self-
worth than older children and adolescents with SS. This appears to be due largely to
the fact that height and height differences are not as apparent or important to younger
children. More specifically, areas in which stature might have a greater negative
impact (e. g. , competitive athletics, social relationships, dating) become more
important with age. Hence, the feelings of self-worth of younger children may be

protected somewhat from the negative effects of SS.

102

Contrary to predictions, there were no significant differences between younger
and older children with S8 in terms of parent-reported behavior problems or
competence. These results differ from those of Holmes et al. (1985; 1986), who
found more significant behavior problems in younger children with SS. It is unclear
why similar group differences were not present in this sample. One possible
explanation may be that in the past, those children who were referred for SS at an
early age were those who manifested more significant behavior problems. Today,
primary care physicians are more aware of the etiology and potential consequences of
SS. Hence, children may be referred for treatment of SS at an earlier age because of
the potential for future psychosocial difficulties, but not necessarily because of current
problems.

An alterative explanation is that this group of older children is functioning
more poorly than would be expected, given the results of previous studies. However,
examination of the individual behavior problem scales of the CBCL leads to a
different conclusion. Neither age group differs from the standardization sample by
more than .78 of a standard deviation. Thus, overall both groups are functioning
fairly well from a behavioral standpoint. The possibility remains that an undetected
age effect was masked by the division into young and old age groups, in which early
adolescents fare more poorly than younger and older children, as suggested by the
Holmes et al. (1985; 1986) studies. Future efforts should focus on these possible age

effects through longitudinal designs.

103
The Impact of a Familv History of SS

Based on theories of social stigma and identification with a stigmatized group,
(Crocker & Major, 1989) children with SS who had a perceived or diagnosed family
history of SS were expected to have better psychosocial adjustment than those
without. This hypothesis was largely unsupported by the data. One unexpected result
was that children who perceived that they had a family history of SS rated themselves
as significantly kg satisfied with their physical appearance than those who did not. It
may be that the presence of a family member with SS is a constant reminder to the
child or adolescent of his or her own SS. This may heighten the child’s sense of
being "different" at a time when being "normal," or identifying with the majority, is
particularly important (Erikson, 1968). In the case of familial short stature,
identification with the stigmatized group may not preserve one’s feelings of self-
worth, as suggested by Crocker and Major (1989).

It would help to know what kind of role models the short family members
provide for children with SS. If a parent or older sibling has had a particularly
difficult time coping with their own SS, and they do not feel good about themselves
or their physical appearance, it is possible that the child or adolescent will internalize
and model this. Alternatively, having negative feelings about a family characteristic
may be a means of separation or individuation for the child or adolescent with SS.

Comparisons of the four diagnostic groups of children with SS produced one
significant difference in the expected direction. Children with FSS and CD/FSS were

rated by their parents as having higher social competence than children with GHD and

104

CD. Young-Hyman (1986) found similar results in that short parents rated their
children with SS as more socially competent than parents of average stature. One
possible reason for this difference is that parents with SS themselves may more
strongly facilitate their child’s social relationships, as they may be more keenly aware
of their importance. An alternative but compatible explanation is that parents with SS
themselves may rate their children as more socially competent as a defensive or
compensatory mechanism in which they perceive their child more positively than
taller parents. While not directly related to this area of research, other studies have
found such compensatory processes in the parent-child relationship. Specifically,
parents buffer the negative effects of stress on their children and work harder to make
interactions with their children more positive in the context of greater parenting stress
(Engfer, 1988; Brody et al., 1986; Belsky et al., 1990).

While few studies have examined differences between the diagnostic groups of
children with SS, those that do indicate significantly more psychosocial problems in
children with CD. In the present study, children with CD were rated as having
significantly more problems on only one scale, social competence. Thus, the range of
problems previously reported (learning difficulties, inattention, immaturity, and
hyperactivity) in children with CD (Gold, 1978; Gordon et al, 1982; 1984) did not
emerge in this sample. However, there is some indication that children with CD have
more difficulties in their social relationships. It can be speculated that the
combination of both SS and delayed onset of puberty is particularly damaging to these

children’s social relationships. Although the delayed onset of puberty would only be

105
an issue for those children whose peers were entering puberty, 62.5% of the children

with CD in this sample were 12 years old or older. Thus, the majority of these
children potentially were behind their age mates in both growth and sexual
maturation. This puts them at an even greater disadvantage socially, as pubertal
development is valued among their peers (Martel & Biller, 1987) and size and
strength become increasingly important in judgments of physical attractiveness,
athletics, and even the ability to perform jobs. In addition, the combination of
delayed pubertal development and SS would exacerbate the discrepancy in physical
appearance between children with CD and their normally-developing peers, making
them appear even younger. Consequently, late—developers who are also short are
more prone to juvenilization. More immature, dependent, and impulsive social
behaviors on the part of late-developers (see Martel & Biller, 1987) are at least in
part due to social expectations, juvenilization, and a recurring cycle in which the less
socially competent behaviors perpetuate a view of the child with CD as less mature

emotionally and socially.

The Importance of Physical Appparance

 

In this study both children with SS and those with NS rated physical
appearance as moderately important to them. This is similar to Harter’s (1986)
finding that children found it difficult to devalue physical appearance. In addition,
there was a significant relationship between satisfaction with physical appearance and

global self-worth, and this was stronger for children with SS than those with NS. As

106
predicted, children with SS who devalued physical appearance rated themselves as

more competent in school and athletics than those who valued it more. It may be that
particular strengths in academics and sports allowed these children to place less
emphasis on the way they look. Children in the devaluing group also reported higher
feelings of overall self-worth, and were more satisfied with their appearance. It is
unclear whether satisfaction with appearance enabled these children to place less
emphasis on it, or whether devaluing appearance facilitated feelings of satisfaction.
This is an area in need of further investigation.

Contrary to predictions, devaluing physical appearance was not associated with
fewer internalizing behavior problems. In fact, children in the devaluing group were
rated by their parents as having more somatic complaints than children in the group
which valued physical appearance. Perhaps for at least some of the children in the
devaluing group, repression or denial of the importance of physical appearance is
associated with greater somatization (e.g. , Mitchell et al. , 1986 & Zimet et al. ,

1993).

Family Factors in Child Outcomes

Failure to find differences between families of SS and NS children on the
controlling factor may be due in part to the clinical setting from which the SS patients
were drawn. The Michigan State University Endocrine Clinic is staffed by a multi-
disciplinary team which includes a psychologist and social worker. Considerable

attention is paid to psychosocial issues surrounding each child’s diagnosis and

107

treatment. Hence, families of children with SS recruited from this setting may be
more sensitive to psychosocial issues, and in particular to overcontrolling and
juvenilization, than parents of children receiving treatment elsewhere.

Post-hoe analyses comparing families of children with SS and NS on the
support and conflict factor produced one interesting result. Whereas the families did
not differ in terms of conflict, families of children with SS described themselves as
somewhat less supportive. While this difference was not statistically significant
(p=.11), one could speculate that a larger n would have produced a significant
difference. The support factor is comprised of the following scales: cohesion,
expressiveness, activity/recreational, intellectual/cultural, and independence. Perhaps
stresses associated with the diagnosis and treatment of SS result in a breakdown of
family support at multiple levels. First, parents may not agree on whether there is a
problem, and how to handle it. This could result in communication difficulties
between parents. Second, issues around independence may arise in the parent-child
relationship (e.g. , who is responsible for what part of the treatment, age-appropriate
expectations, concerns about participation in sports). Third, siblings of children with
SS may find it difficult to be supportive of patients because they view them as
receiving more of their parents’ time and attention. Fourth, altogether the family may
have difficulty sharing concerns, and may prefer to "not talk about the problem."
Additionally, the financial burden incurred by some families as a result of treatment
with GH may limit their ability to spend time together in recreative pursuits.

The semi-structured interviews provide some evidence for a deterioration of

108

support in some families. One family had two adolescent sons with CD, the younger
of whom was a study participant. When contacted about the study, the mother
requested that the father not be contacted because he would be "mad. " Apparently,
the father disagreed with the mother about whether the boys had a problem, and about
treatment decisions. Hence, the mother took sole responsibility for the boys’ medical
care. Both boys had received treatment with testosterone, the cost of which was not
covered entirely by their insurance. Because of the high cost of treatment, the
company the father worked for allegedly raised their insurance premiums.
Subsequently, the father received considerable negative feedback from his co-workers
because their premiums similarly increased. In addition, the mother reported feeling
ostracized from their place of worship, as the community reportedly felt that the boys
should not receive medical treatment for a trait with which they were born. The
older brother was unable to be supportive of the younger brother, as he allegedly had
significant difficulty coping with and accepting his own CD, and refused to talk about
it. The study participant excelled in wrestling, and gained considerable esteem from
his success in it. He verbalized feeling that his father could not accept his sons
because they did not live up to his expectations. In spite of this somewhat bleak
scenario, this young man was able to cope fairly well with his condition and maintain
a high sense of self-worth. The support he received from his mother appeared to help
buffer him from other stresses both within and outside the family.

Overall, family support was the factor most strongly related to child

adjustment in terms of both child self-perceptions and parent reports of child

109

competence and behavior problems. Family control and conflict were only related to
parent-reported behavior problems, and conflict had the fewest significant
associations. Family support was associated with greater child competence and self-
worth, and fewer behavior problems, while both conflict and control were associated
with greater behavior problems. These results are comparable to the growing body of
research that links factors of the family environment to child outcomes. Inconsistent
with this literature is the failure of the present analyses to find links between the
control and conflict factors and child self-worth. In addition, based on the large body
of research linking family conflict to poor child self-esteem and behavior problems,
there were fewer associations overall than would be expected between the conflict
factor and child outcomes (see Jaycox & Repetti, 1993). Lack of associations
between these variables may be attributable to the measures of control and conflict.
Specifically, combining the individual scales of the PBS into the three factors may
have diluted some of the individual associations the scales might have had with the
outcomes. Supporting this argument is the fact that much of the research uses the
single conflict scale of the PBS as the measure of family conflict (Jaycox & Repetti,
1990; Moos & Moos, 1986; Murch & Cohen, 1989). Kronenberger and Thompson
(1990), the researchers who developed the factors, only assessed relationships
between the mothers’ scores on the factors and mothers’ reports of child behaviors.
The present results are similar in that conflict is associated with externalizing
behaviors. However, they differ in that an association was found between control and

externalizing behavior, as well as total problem behaviors and other narrow band

110

scales, not reported by Kronenberger and Thompson (1990). In addition, using
individual scores rather than family composite scores on the family factors might have
yielded different results.

Combining the three family factors into a constellation of high support, low
conflict, and low control permitted comparisons between this hypothesized "ideal"
family environment and all others. Children from families with this constellation
were rated as having fewer externalizing and delinquent behaviors, and they reported
greater satisfaction with their own physical appearance. Failure to find more
significant differences between the family groups may be due in part to the fact that
families were divided into low and high groups on each factor. This dichotomization
may have masked effects, especially those attributed to family control, which may be
most adaptive at moderate levels. This assumption is based on Baumrind’s (1967)
parenting typologies, and data indicating that a moderate level of control, or
"authoritative" control, fosters more positive child adjustment in general, and self-
esteem in particular (Baumrind, 1967; Buri, 1989). In families coping with child
chronic illness (and specifically SS), a moderate level of control might be particularly
facilitative of adequate child adjustment. A moderate level of control may provide
children with SS with the confidence that they can master developmental tasks

independently, while providing them with enough guidance that they feel supported.

Coping

Research hypotheses regarding coping were only partially supported by the

1 11
data. Child coping was only significantly related to fathers’ coping, and not to

mothers’. Stronger father—chfld rather than mother-child relationships on coping
parallel the results of previous studies in which: a) fathers’ behaviors had a greater
impact on adolescent self-esteem than mothers’ (Gecas & Schwalbe, 1986), and b)
fathers’ acceptance was the strongest predictor of adolescents’ functioning in the
school setting (Forehand & Nousiainen, 1993). These results may be interpreted
several ways. Considering a social power differential, fathers traditionally hold the
most authority and power within the family. Thus, children may be more likely to
model their fathers’ rather than their mothers’ behaviors. In addition, with the
increase of females’ entering previously male-dominated roles, it would be more
socially acceptable for girls to identify with a masculine role model than for boys to
identify with a feminine role model (i.e. , their mothers). Alternatively, others have
speculated that fathers’ lesser involvement in child-rearing and socialization may make
their interactions with children that much more salient (Forehand & N ousiainen,
1993; Gecas & Schwalbe, 1986). Children may also strive harder to gain their
fathers’ approval and attention through behaviors that they believe fathers value.
With regard to coping with SS in particular, Rotnem et al. (1982) report that fathers
had more difficulty accepting their child’s diagnosis than mothers. Within this
context, children may find coping with their diagnosis of SS that much more
challenging.

In general, child coping was not strongly related to child adjustment. The

only relationship in the predicted direction was a negative association between

112

approach coping and social withdrawal. One unexpected finding was a positive
relationship between approach coping and somatic complaints. Or, alternatively
worded, those children who used more avoidant coping strategies were rated as
having fewer somatic complaints. At first glance this relationship appears
counterintuitive, given the existing literature relating less positive child adjustment to
avoidant coping. However, it makes sense within the framework of chronic illness
and coping proposed by Phipps, Fairclough, & Mulhem (1995). Examining the
coping processes of children with cancer, these authors reframe what previously has
been referred to as "repressive adaptation, " as an avoidant coping style they labeled
"blunting". While both processes have similar results, "protecting the self from full
awareness of threatening aspects of reality (Phipps et al., 1995, p. 218)," blunting is
more purposeful and under more conscious control, and therefore a coping (rather
than a defensive) mechanism. These authors found more blunting responses in their
sample of pediatric oncology patients than in a comparison group. They attribute the
previously reported lower rates of depression in children with cancer to this blunting
(avoidant) coping style, albeit more primitive than a monitoring/ approach style.
Thus, in the present study avoidant coping may protect children from
threatening/distressing knowledge or experiences, and hence result in lower somatic
complaints.

Taken together, this theoretical framework and the results of this study call
into question the view of one coping strategy as more adaptive than another. Both

approach and avoidant strategies serve the purpose of protection against stress.

113

Whether one type of response is linked to more positive outcomes than the other
appears to be largely situation-specific. For example, the same strategy may not be
equally adaptive for pediatric oncology patients or children with SS as it is for healthy
"normal" children. Future efforts should focus on clarifying which coping strategies
lead to more positive outcomes and under what conditions.

Failure to find more significant correlations between child coping and child
adjustment may be due to problems with the current method of rating coping
responses. This will be explored further below. In addition, analyses including the
child coping variable included a smaller number of subjects, as all subjects did not
produce coping responses in their semi-structured interview. A reduction in the

sample size likely reduced the chance of finding significant results for coping.

The Stress and Coping Model

Before examining the stress and coping model, relationships between the
predictor and outcome variables were tested With Pearson correlations. Some of these
results are notable. First, of all of the child outcomes, academic competence had the
fewest significant correlations with the predictors. Only SES and both parents’ global
self-worth were significantly and positively related to child academic competence.

Among the relationships between the family mediational variables and child
adjustment, a few were opposite to those which were expected. For example,
mothers’ approach coping was negatively related to child social competence while

fathers’ approach coping was positively related to child behavior problems. These

114

results indicate that some aspect of parents’ approach coping is detrimental to child
adjustment. It is possible that approach coping could reflect a general style of being
more assertive or confrontational, without necessarily being hostile. If this style were
reflected in mothers’ or fathers’ parenting or child-rearing practices, it might be
experienced by children as intimidating or aggressive. In addition, if children were to
model this behavior, it might be judged as socially inappropriate or aggressive. This
might account for higher parental reports of behavior problems and lower social
competence.

Of similar interest was the positive relationship between mothers’ negative
impact of stature score and child social competence. This relationship may be further
evidence of a compensatory process whereby some parents (especially mothers) take
extraordinary strides to protect their children from stress. In this case, mothers who
themselves experienced difficulties as a result of their height may go out of their way
to protect their child from similar experiences. Hence, they may facilitate the child’s
social competence by encouraging the child’s involvement in social activities or peer-
oriented organizations (e.g. , sports teams, scouts, sleep-overs). The opposite
relationship between fathers’ negative impact of stature score and child social
competence may suggest that mothers’ are more likely to buffer their children in a
compensatory mechanism than fathers. In addition, fathers’ own experiences appear
to more directly "spill-over" into their relationships with their children (Engfer,
1988). Evidence of stronger buffering in the maternal caregiving system lends some

support to these speculations (Easterbrooks & Emde, 1988).

115

Given the proximal relationship of the child mediational variables and the
outcome variables in the model, there were fewer significant correlations between the
two than were expected. Specifically, social competence was the only outcome
associated with the child mediational variables of global self-worth and negative
impact of stature (-). The lack of associations between child coping and the outcome
variables are inconsistent with previous findings (Causey & Dubow, 1992; Compas,
1988; Ebata & Moos, 1989). Differences in measures of coping may have led to
these disparate results. Specifically, child coping has primarily been assessed by self-
report measures, whereas the present study utilized a semi-structured interview to
elicit coping responses. Since children generated their own examples of stressful
events/experiences and the coping strategies they used to deal with them in this study,
a more limited range of responses was given than would be available in questionnaire
measures. In addition, because of the open-ended nature of the interview, in many
cases no coping responses were elicited. Other difficulties with the present measure
of coping are discussed below.

In the first phase of the analysis of the stress and coping model,
stature, fathers’ coping, and fathers’ positive impact of stature score all predicted a
significant amount of variance in total behavior problems. Family demographic
parameters and child mediational processes failed to account for any variance in total
behavior problems. These results differ from those of Thompson et al. (1992b), who
found that child self-worth accounted for significant variance in both mother-reported

internalizing and externalizing behaviors. This set of analyses highlights the

116

importance of fathers’ behaviors and experiences (namely coping and positive impact
of stature) with regard to child adjustment. The results are also consistent with those
of earlier analyses in which children with SS were rated as having more behavior
problems than their peers of NS.

The stress and coping model failed to predict any of the variance in child
academic competence. In addition, when the model was run predicting social
competence, it suffered from collinearity between the child coping and stature
variables. Hence, the second phase of the analyses involved running the regressions
on a trimmed model which excluded all family members’ coping. These analyses
provided somewhat more reliable results.

Analyses of the trimmed model for total behavior problems as the outcome
revealed that diagnostic/demographic parameters accounted for 27% of the variance,
and family conflict accounted for an additional 5 % of the variance. Again, child
mediational factors were not predictive of total behavior problems. For academic
competence only stature accounted for a significant amount of the variance (14 %),
with children with SS faring more poorly than children with NS. lastly, in the final
set of analyses for social competence, stature accounted for 25% of the variance,
while family mediational processes, (family support, mothers’ positive impact of
stature, and fathers’ negative impact of stature), accounted for a 24 % increment in
variance. Child mediational processes failed to enter the model.

Overall, the results lend support to the mediational role of family factors in

child behavior problems and social competence. In particular, both parents’ coping

117

and impact of height scores, as well as family conflict and support, were predictive of
child adjustment in the models tested. Of note is the fact that the family mediational
processes were assessed by parent and child self-report, and behavioral observation.
Contrary to the predicted relationships in the stress and coping model, no support was
provided for the inclusion of child mediational processes (children’s self-worth,
coping styles, and the impact of stature). It is unclear why the child mediational
variables were not predictive of child adjustment. However, it is possible that these
variables are better thought of as additional child outcomes, rather than mediators.
Because of problems of collinearity in the child coping variable, it is unclear what
role it has in the model. An additional problem with the coping variable may be that

it is a proportion score, and therefore bounded.

Study Limitations and Future Directions

The current study has a number of limitations which should be considered
when interpreting the results. A considerable shortcoming is the relatively small
sample size. This appeared to contribute to fewer significant results and to problems
of collinearity. Also due to the small sample size, any conclusions regarding the
results should be viewed with caution. Another obvious limitation of this study is its
cross-sectional and correlational design which precludes making assumptions about the
direction of causality between the study variables. A longitudinal design would allow
for the examination of "stability and change in psychosocial adjustment,

psychosocial/mediational processes, and their interrelationship, over time and in

118

relation to developmental tasks and periods of risk and resiliency" (Thompson et al. ,
1992b, p. 754).

There were a number of pitfalls in the assessment of parents’ and children’s
coping. Because of the open-ended nature of the interview, it frequently failed to
elicit coping responses, especially for subjects of NS and their parents. In addition,
parents of children with SS were more likely to produce coping responses related to
their child’s diagnosis and treatment. This may have inflated their tendency toward
approach c0ping relative to parents of NS children, because they were coping with
problems related to their child. More specifically, it may be easier for parents to
cope in a proactive or approaching style where their child is concerned, as opposed to
coping with a problem of a more personal nature (e.g., being overweight). These
observations are supported by the significant and moderate correlations between
parents’ approach coping and child stature in the negative direction. In addition, the
method of coding did not take into account developmental changes in subjects’ coping
strategies. With regard to the model of stress and coping, a considerable amount of
variance remained unaccounted for in the outcomes. The model should be expanded
to include: degree of medical involvement/intrusiveness of treatment, parents’ and
children’s stress appraisal, parents’ psychosocial functioning, and children’s cognitive
abilities. Rather than dividing stature into SS and NS groups, it might be better if
measured in terms of deviation from the mean for age.

The present study has a number of noteworthy strengths. It included a fairly

homogeneous sample of children with SS who were compared to a group of carefully

119

matched control subjects of NS. In addition, the combination of parent and child self-
report and observer ratings avoided problems associated with common method
variance. Further, the results provided some support for the validity of the coping
and impact of stature ratings. More importantly, this study clarified the nature of the
relationships between family factors and children’s psychosocial adjustment to SS.
The inclusion of fathers in the study provided a view into family processes which has
historically been neglected. The results indicate that fathers’ behaviors and
experiences have unique and especially strong contributions to children’s adjustment.
Finally, the model of stress and coping provided a conceptual framework from which
to assess the relationships between diagnostic/demographic parameters, family and
child mediational processes, and child adjustment.

The results of this study have significant implications for future research
efforts and intervention programs. Subsequent investigative efforts of family factors
in children’s psychosocial adjustment to SS should correct the methodological flaws of
the present study, especially those concerning coping. The interview needs to be
more structured and more specific with regard to the nature of the stressor,
developmental changes in coping strategies, and perceived effectiveness of the coping
strategy. Data obtained from the interview should be corroborated with a multimodal
assessment of coping including parent-, teacher- and peer-report, as well as behavioral
observation.

The results of this study also indicate a clear need for supportive intervention

for children with SS. While the present group of children with SS appear to be

120

functioning well overall, they do manifest areas of particular difficulty as compared to
a matched group of children with NS. Specifically, these children with SS have
social difficulties and more behavior problems, especially those of an internalizing
type. In addition, they report deficits in their feelings of self worth, athletic
competence, and satisfaction with their physical appearance. These results also
delineate a clear need for the early identification and referral for treatment of girls
with SS. While girls and boys with SS were more similar in their outcomes than
expected, the girls had more difficulties with internalizing behaviors, participated in
fewer extracurricular activities, and felt less positive about their athletic abilities and
physical appearance. These results also highlight the importance of family factors,
especially, parents’ own experiences and behaviors, in child adjustment. In
particular, fathers’ variables were more strongly linked to child outcomes than
mothers’. In light of fathers’ lower levels of participation in the study, it appears that
extra efforts should be made to include them in intervention programs.

Very little published work is available regarding psychosocial interventions
with children of SS. However, preliminary results are promising (Eminson, Powell,
& Hollis, 1994). While both children with S8 and their families are in need of
support, it appears that support alone is not sufficient to alleviate areas of concern
(Eminson et al., 1994). Social skills training, coping skills building, and cognitive
problem-solving should be used in combination with support groups for parents,
patients, and siblings. Parents should be included in the skills training so that they

can reinforce the concepts and behaviors being learned. Family sessions might also

121

serve to bolster feelings of support within the family, moderate issues of control, and
decrease areas of conflict, especially those pertaining to the diagnosis and treatment of
SS. In addition, the intervention should include a didactic component in which
subspecialty team members (e.g. , physicians, nutritionists, nurses, social workers, and
psychologists) address areas of concern for the children and their families.
Intervention should also include facilitation of the children’s involvement in non-
threatening social activities and organizations in which success is not dependent on
stature. Considering the cost of pharmacological treatment of SS, and a failure to
demonstrate clear and consistent improvement in psychosocial symptoms with
hormone therapy, this line of psychological intervention should be the focus of future
research efforts and may be promising, especially for short "normal" children

experiencing psychosocial distress.

APPENDICES

APPENDIX A

APPENDIX A

Frequently Used Acronyms
SS = short stature
GH = growth hormone
GHD = growth hormone deficient
IGHD = isolated growth hormone deficiency
MHD = multiple hormone deficiency
CD = constitutional delay of growth
F SS = familial short stature

NS = normal stature

122

APPENDIX B

APPENDIX B

MICHIGAN STATE UNIVERSITY

 

DEPARTMENT OF PEDIATRICS/MAN DEVELOPMENT EAST LANSING 0 MICHIGAN 0 48824-1517
8240 LIFE SCIENCES
($17) 333-5042

MEMO
FROM: Pediatric Endocrinology Clinic
TO: Parents of children referred for evaluation of short stature

Dear Parents:

Our clinic is conducting a study about the impact of stature on children and their families,
and we would like to invite your family to participate. We are trying to better understand how
children and their families perceive and experience different aspects of height. Based on the
information families share with us, we will develop services to address areas of concerns,
especially those pertaining to short stature.

Participation in this study includes an interview of the parents and the child and
completion of a few questionnaires. The interviews will take about 30 minutes each and will
be conducted by a pediatric psychologist. You always have the right to refuse to answer a
question. The interview provides you with an opportunity to share your droughts and concerns
about the issue of height. The questionnaires provide us with a description of your child,
yourself, and your family, and can be completed at your leisure at home.

You will receive a phone call from one of our team members to describe the study
further and to ask whether you are interested in participating. If you do decide to participate,
we will schedule your interviews over the phone, either on the day of your next appointment
with our clinic, or at a more convenient time for you and your family. If it is not possible for
the interviews to be done in person, they may be done over the telephone. Questionnaire
packets will be distributed either at the time of the interview, or sent out in the mail. All of
your family’s responses will be confidential and your decision to participate will not affect your
child’s treatment at our clinic in any way. In addition, participation may be terminated at any
time, and you may refuse to answer a question.

We appreciate your taking the time to consider participating in this research project. We
hope that it will be an interesting and helpful experience to all participants. You should expect
to receive a phone call within a week of receiving this letter.

p.429» Car/mt Cygauzgrmq.
Bruce E. Wilson, MD. Carol C. Laub, M.A.
Pediatric Endocrinologist Pediatric Psychology Fellow

123

APPENDIX C

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

University Committee on
Research Involving
Human Subjects
(UCRIHS)

Michigan State University
225 Administration Building
East Lansmg Michigan
48824-1046

FAX 5l7/335.ll7l

APPENDIX C

MICHIGAN STATE

 

UNIVERSITY

January 28. I994

TO: Dr. Bruce E. Wilson
8240 Life Sciences Building

RE: IRB #:

TITLE:

9l-076
PSYCHOSOCIAL ADAPTATION AND SUPPORTIVE INTERVENTION IN

FAMILIES WITH CHILDREN WITH SHORT STATURE

REVISION REQUESTED: N/A
CATEGORY: Full Review
APPROVAL DATE: January 11, I994

The University Committee on Research Involving Human Subjects’ (UCRIHS) review of this project
is complete. I am pleased to advise that the rights and welfare of the human subjects appear to be
adequately protected and methods to obtain informed consent are appropriate. Therefore, the
UCRIHS approved this project including any revision listed above.

Renewal:

Revisions:

Problems]
Changes:

UCRIHS approval is valid for one calendar year, beginning with the approval
date shown above. Investigators planning to continue a project beyond one year
must use the green renewal form (enclosed with the original approval letter or when
a project is renewed) to seek updated certification. There is a maximum of four
such expedited renewals possible. Investigators wishing to continue a project
beyond that time need to submit it again for complete review.

UCRIHS must review any changes in procedures involving human subjects, prior
to initiation of the change. If this is done at the time of renewal, please use the
green renewal form. To revise an approved protocol at any other time during the
year, send your written request to the UCRIHS Chair, requesting revised approval
and referencing the project’s [RB # and title. Include in your request a description
of the change and any revised instruments, consent forms or advertisements that are
applicable.

Should either of the following arise during the course of the work, investigators
must notify UCRIHS promptly: (1) problems (unexpected side effects, complaints,
etc.) involving human subjects or (2) changes in the research environment or new
information indicating greater risk to the human subjects than existed when the
protocol was previously reviewed and approved.

If we can be of any future help. please do not hesitate to contact us at (5I7) 355-2I80 or FAX (SI?)

336-l l7l.

Sincerely,

 
 
  

UCRIHS Chair

David E. Wright. Ph.D.

125

APPENDIX D

APPENDIX D

MICHIGAN STATE UNIVERSITY

 

DEPARTMENT OF PEDIATRICS/HUMAN DEVELOPMENT EAST LANSING 0 MICHIGAN 0 48824-1317
3240 LII-E SCIENCES
(517) 355-5042

Informed Consent:

Our clinic is conducting a study about stature and we would like to invite your family to
participate. We are trying to better understand how children and their families perceive and
experience different aspects of height. Based on the information families share with us, we will
develop services to address areas of concern, especially those pertaining to short stature.

Participation in this study includes an initial interview of the parents and the child, and
completion of a few questionnaires. The interview will be conducted by a pediatric
psychologist, and each person always has the right to refuse to answer a question. The interview
will be similar to one we routinely use in other subspecialty clinics. Many families have found it
very helpful to share their thoughts and ideas in greater detail. Often, it is the first opportunity
for everyone to share their thoughts and/or experiences about the issue of height.

The interview will take approximately 1 1/2 hours altogether, and it will be held at the
M.S.U. Clinical Center, or by telephone when it is not possible to conduct it in person. There
will also be a few questionnaires for you to fill out. YOUR ANSWERS WILL BE CONFIDENTIAL
AND WILL NOT BE PART OF YOUR CHILD'S CLINICAL CENTER RECORD.

Interviews will be videotaped or audiotaped, in order to facilitate data collection. At any
time during the interview, any person may request that the tape be discontinued or erased. You
always have the option to have the tape erased. We will also address any questions you may
have regarding the use of these tapes for data collection.

Summaries of the information we gather, and statistics used will be based on group data,
but will not identify individuals or their families. All families who participate will receive a copy
of our findings and recommendations upon request.

If you choose not to participate, your child's medical evaluation and care will not be
affected in any way.

If your family would like to participate in this study, please sign below and check which
level of participation you desire.

 

 

 

 

 

 

Family interviews and questionnaires. _ Questionnaires only.
Mother’s Signature Date
Father’s Signature Date
Child’s Signature Date

126

APPENDIX E

APPENDIX E

MICHIGAN STATE UNIVERSITY

 

DEPARTMENT OF PEDIATRICS/HUMAN DEVELOPMENT" EAST LANSING 0 MICHIGAN 0 488244317
8240 UFE SCIENCES
(SI?) 353-5042

Dear

We appreciate your willingness to participate in our study investigating parents’ and
children’s perceptions and experiences related to height. We are interested in how and
in what ways individuals’ stature may have had an impact on their lives.

Please find enclosed a set of questionnaires for you and to complete at
home. All instructions are included and are fairly self-explanatory. However, on
occasion families have questions on how to complete the forms. Should questions arise
in your family, please do not hesitate to call me at 353-5042. Leave a message and I
will get back to you as soon as possible.

It is veg important that everyone complete these questionnaires individually. If you
would like to discuss your answers, please do so only after everyone is finished. If

needs assistance in understanding how to complete the
questionnaires, please help to explain the instructions, but do not help in choosing
answers.

 

We have provided you with a self-addressed, stamped envelope for returning the forms
to us. We appreciate your investment of time and effort and hope that this will be an
interesting experience for your family.

Sincerely,

chgw

Carol C. Laub, M.A.
Pediatric Psychology Fellow

 

Eliza h A. Seagull, Ph.D. /’
Pediatric Psychologist
Supervisor

127

APPENDIX F

APPENDIX F

CHILD AND FAMILY INFORMATION: STATURE PROJECT

1.) ID Number

 

2.) Date of Interview

 

3.) Age

 

4.) Date of Birth

 

5.) Sex 1. Female
2. Male

6.) Relationship to the child:

. Mother

. Father

. Step-mother

. Step-father

. Other (specify)

Ul-hbJNI-t

 

7.) Marital Status:
1. Never married
2. Married
3. Separated
4. Divorced and Single
5. Divorced and Remarried
6. Widowed
7. Cohabitating
8

. Other (specify)

 

8.) If applicable, how many years have you and your mate been together?

 

9.) What is your ethnic heritage?
. European American (White)
. African American

. Hispanic (Black)

. Hispanic (White)

. Asian American

. Native American (Indian)

. Other (specify)

\IQM-hWNi—t

 

10.) What is your mate’s ethnic heritage? (Use numbers above.)

 

128

129

11.) What is your religion?
. Protestant (specify denomination)
. Roman Catholic

. Orthodox

. Jewish

. Moslem

. None

. Other (specify)

 

\IGIJIAUJNr—t

 

12.) What is your mate’s religion? (Use numbers above.)

 

13.) What was the last grade in school that you completed?
. 8th grade or less

. some high school

. high school degree or equivalent (GED)
. some college or 2 year degree

. BA or BS degree

. Master’s degree

. Doctorate

\lQfiIt-h-WNi—A

14.) Did you receive any special education services in school (e.g., special ed. classes,

speech therapy)?
1. Yes
2. N o

If yes, what type(s) of service(s)?

 

If yes, in what grades did you receive this/these service(s)?

 

15.) What was your grade average in Junior High School?
1. A range
2. B range
3. C range
4. D or below

16.) What was your grade average in High School?
17.) What was your grade average in College?

18.) Were there any major changes in your academic performance over time?
1. No

2. Yes (specify)

 

19.) To what do you attribute this change/these changes?
1. Got harder 4. Adjustment difficulties
2. Got easier 5. Peer problems
3. Got help 6. Other (specify)

 

130

20.) Employment status:

“\thlt-BUJNt-t

. Student

. Keeping House
. Work Full Time
. Work Part Time
. Unemployed

. Disabled

. Retired

. Other (specify)

 

21.) Usual Occupation:

. Professional, Technical, Managerial
. Office, Clerical, Sales

. Craftsman

. Entertainer, Musician

. Operative

. Service Worker

. Laborer

. Other

\OWQQth-RWNi—n

 

No work experience

10. Student
11. Homemaker

Describe Occupation

22.) Mate’s Employment Status (Use numbers above):

 

23.) Mate’s Occupation (Use numbers above):

 

24.) Gross Annual Family Income:

. less than $10,000
. $10,000 to 19,000
. $20,000 to 29,000
. $30,000 to 39,000
. $40,000 to 49,000
. $50,000 to 59,000
. $60,000 to 69,000
. $70,000 to 79,000

\ONQGMDWNv—t

1

$80,000 to 89,000
0. $90,000 and above

25.) Total number of children between you and your mate:

26.) Number of children living in your household:

 

 

APPENDIX G

APPENDIX G

Parents’ Interview

In meeting with parents who are concerned about their children’s growth
delay, we continue to be impressed with their caring, sensitivity, and concern about
their child’s adjustment- at home, in school, and with friends. We would like to
understand more about what is helpful to your child’s adjustment, as well as what
makes coping more difficult.

Since children’s perspective and understanding may be limited by their age, or
level of development, we are interviewing both children and parents in this study to
gather information on the impact of height. We would like you to tell us about your
own experiences. As you were growing up, how did your height affect you- in what
areas, at what ages? Maybe it had little effect, and other characteristics or abilities
were more important to you. We would like to know that. We are trying to better
understand when and how height impacts on people so that we can offer information,
groups, or programs for those specific concerns that may be helpful to kids’
adjustment. We value whatever you can tell us , or remember, in answer to these
questions. If you do not want to answer any of these questions, please feel free to let
me know, and I will move on.

1.) First of all, can you tell me who was in your family when you were growing up?
(complete genogram)

2.) Were there any other people in the household that you haven’t mentioned?

3.) For each of these people, did you think they were of average height, below or
above average height for their age? (complete for each family member)

4.) Were there any medical or emotional concerns for each person that you
mentioned?

5.) How would you describe yourself physically? (probe for height-above, below, or
average)

Is the way that you have just described yourself physically, different from how
you saw yourself in the past?

(If yes, what led to the changes?)

In thinking back to how it was for you growing up:

131

132
6.) In general, how much do you think your height affected you and your life?

When was the first time you became aware of your height as something
important?

What were some positive aspects of it?

What were some negative aspects of it?

As I mentioned above, sometimes people’s height and their experience with it
changes with age. Have you always felt like this (refer to answer in #6), or
was it different when you were in elementary school, middle school, high
school?

7.) What kind of judgments do you think people made of you, based on your height?

8.) In your family, did anyone ever make comments about your height, tease you, or
joke about it? (if so, probe for:)

Who made what comments?
How did it feel?
How did you handle it?
How did your parents handle it?

9.) With other kids your own age, what height ever something that was an issue?
With kids the same sex? Opposite sex?
Do you think your height ever affected your social life or dating?

10.) What did you do in your spare time? Hobbies? Sports? Extracurricular?
Did your height affect what you decided to do in these areas?

11.) In school did you feel shorter/taller/or the same as other kids in your class?
Sometimes if kids feel self-conscious for one reason or another, they may find
it hard to concentrate , or to do their work. Do you think your height affected

how well you did in class? (if so probe further)

12.) Do you think your height affects you in your job, or getting hired? (or for
those not working, "in your life as an adult now ")

13.) In what ways do you think your life would have been different if you had been:

133

Taller?
Shorter?

14.) Can you remember an experience from your growing up, which involved your
height or physical appearance which felt very positive, or made you feel very happy,
proud, or joyful?

If yes, can you describe this for me?

15.) Can you remember an experience from your growing up involving your height
or physical appearance which was very hurtful to you, or where you felt very angry,
sad, or ashamed?

If yes, can you describe this for me?

16.) Have you ever known anyone else who had a difficult time in life because they
were especially short or tall?
If yes, indicate the height problem, and describe the incident.

17.) Do you think the impact of height is different for boys than it is for girls?
If yes, describe.

Now I want to ask you just a few questions about (child’s name)...

18.) What did you observe which first concerned you about his/her height? (Had
others mentioned anything?)

How old was s/he when this first occurred?
What do you think the cause is behind his/her growth delay?
What do you hope will come out of your contact with the Endocrine clinic?

19.) What specifically worries you about how (child’s name) will adjust to his/her
present growth level?

20.) Do you have any other concerns about (child’s name) that may not be related to
his/her height?

APPENDIX H

APPENDIX H

Children’s Interview

I understand that you came to the MSU Endocrinology Clinic because you or
your parents wanted to make sure that you were growing OK. Is that right? Were
there any other reasons?

We are doing a study to find out from kids and their parents what they think about
their height, and how that feels to them. I’m going to ask you several questions, and
we’d like you to help us out by answering them the best way you know how. If you
don’t understand a question, stop me, and I’ll explain it better. If you don’t want to
answer a question, just tell me, and I’ll go on to the next one. Are you ready?

1.) First of all, who is in your family? (construct genogram)
2.) Are there any other people in the home that you haven’t mentioned?

3.) For each of these people, do you think they are shorter, taller, or the same as
other people their age? (record for each person listed)

4.) Do you think you are shorter, taller, or the same as other people your age?
(If different, probe for a little, a moderate amount, or a lot...)

Is the way that you just described yourself physically, different from how you
saw yourself in the past?

(If yes, "What led to the changes? ")

5.) In general, how important do you think your height is? (probe for extent of
importance- a little, moderate amount, a lot)

6.) Do you think other people notice your height?
(If so, "What do they think about it?")

7.) In your family, does anyone ever make comments about your height, tease or
joke about it? (if so, probez)

Who made what comments?

How did it feel?

How did you handle it?

How did your parents handle it?

134

135

8.) With other kids your own age, is height ever a problem, or something they talk
about?

With kids the same sex? Opposite sex?

Do you think your height affects who your friends are?
(if older, "Do you think it affects dating? ")

9.) What do you do in your spare time? Hobbies? Sports? Extracurricular?
What do you think you’re best at?

10.) In school, do you feel shorter/taller/or the same as other kids in your class?
Sometimes if kids feel selficonscious for one reason or another, they may find
it hard to concentrate or do their work. Do you think your height affects how
well you do in school? (if so probe further)

11.) In what ways do you think your life would be different if you were:

Taller?

Shorter?

12.) Can you remember a time when you felt really good because someone said
something about your height or you could do something special because of it?

If yes, "Can you describe this for me?"

13.) Can you remember a time when you felt really bad because either someone
made fun of you, or you couldn’t do something because of your height?

If yes, "Can you describe this for me? "
14.) Have you known anyone else who had a hard time in life because they were
especially short or tall?

If yes, indicate height problem, and describe the incident.

15.) Do you think being short or tall is different for boys than for girls?
If yes, describe how it differs.

16.) How do you think your mother feels about her height?
Do you think that’s OK with her?

17.) How do you think your father feels about his height?

136
Do you think that’s OK with him?

18.) Is there anything you’d like to add, that wasn’t mentioned already?

APPENDIX I

APPENDIX I

Coping Coding Manual
APPROACH (Problem-focufl)

problem solving: Ex.: In response to difficulty lifting people at work: "I learned how to do
it with my legs, how to get around it."

seeking support: Telling parents, teachers, friends about teasing, a problem, or feelings.

cognitive decision making: Structuring one’s way of thinking about something so as to make
it more acceptable.
Ex.: "I just have a different way of coping with me being small and stuff like that. I didn’t
care what anyone else thought of me, it was just what I thought of myself."

"I always thought that when someone made fun of you it was because something was
lacking in them."

confronting the situation or individugl: Ex.: In response to friends teasing other short
people: "I say well look at me, I’m like that too.”
"If someone would ask me why I’m so short I’d just tell ’em."

selective devaluing: Placing less value on an attribute in which one fares poorly.
Ex.: "When I think of all the things that are important about a person, I’ve never really had
trouble adjusting to the fact that I’m below average in height."

"I think that what you know is more important than your height."

_attributing negative experience to preiudice: Ex.: In response to being picked last for
baseball team: "I think it was because of my stature- I really believe that."

comparing self to others with similar qualities/challenges: ."I had some abilities that were
outstanding for my size."

"Compared to the rest of my family, I was normal."
positive reappraisal: Evaluating or viewing a quality or situation in a more positive light so
as to make it more accepatable.
Ex.: "Who I feel sorry for are the really tall people. "

"I think being short has given me more character."

positive self-nit: " I think in my head, ’I’m gonna be taller than this person, then when they
see me they’re not gonna make a joke about it because they’ll know I’m serious.”

positive acceptance: "I thought I didn’t have any control over it [height] so why worry."

137

138

compensation: Compensating for lack of ability or perceived inadequacy in one area by
learning to excel in another.
Ex.: "I might go out for the swim team because height doesn’t matter."
"My pride came with accomplishments-succeeding in school."

1 3 9
AVOIDANCE (Emotion-focused)

avoiding: "I deliberately did not want to participate in any kind of sport because I was so
awkward and slow and even when I gained my full abilities back I was apprehensive of that."

distracting: Doing something to take mind off of stressor. "I just became a workaholic."

ignoring: "I was the type that just ignored it."
"We just walk away from the situation."
"I just don’t even pay attention to them."

denying: Child says taller than other kids when in reality they are the shortest in their class.

Frequent responses of "I don’t know."

Contradictory responses (e.g., little girl says it makes her sad to be short and would
do anything to get taller, then later says she’s not really worried or concerned about her
height).

"It’s not important at all. It really doesn’t matter." (Then later discusses how much
he would like to be taller).

emoting/emotional discharge: Responses which are driven by emotions, rather than
cognitions (e.g., yelling, physical aggression, crying).

Ex.: "But then I learned to tease them back when I got a little bit older. What goes around
comes aroun ."

self-blaming: "I was like why am I so short and stuff like that, Why’d I have to be so short,
and stuff like that, so small."

minimizing: Downplaying the importance or negative impact of a quality, situation, or
feeling.
Ex.: "They’re just a couple inches taller than me so it don’t matter. "

"It doesn’t really bother me tht much."

cognitive avoidance: "Forget about it. Just erase it from your memory. Don’t think about
it. "
resigned acceptance: Subject demonstrates that s/he feels helpless or resigned to situation,
without positive resolution of negative feelings.

"There’s nothing anybody can do about it. I just have to take it."

withdrawing: Social or emotional disengagement.
Ex.: "I guess maybe it made me a little bit introverted."

magical/wishful thinking: In response to teasing: "I wished I was like real tall sometimes."

APPENDIX J

APPENDIX J

Sample Coding Sheet

Subj. No. 85—23 Coder: CCL

1.) Family Hx. SS: Yes ; 2.) If yes, family member(s): Father .
3.) Self-description of stature: Below Average
4.) Coping Strategies (AP=appraoch, AV=avoid):

 

AV "1 mean I wasn’t like desperate for an appointment, but I was just curious." (minimizing)

AV "I’m wondering if I would’ve been better off not going [to c1inic]...l don’t know if I h_ad to
know I wasn’t gonna grow any more. Might as well be convinced otherwise." (avoidance)

AV "It was only bad for a couple-for like a day and a half." (minimizing)

AP "I’m just part of a vaguer minority group." (compares self to others with similar attributes)
AV "I started crying when I left [clinic]-like I couldn’t hold it back." (emoting)

AV Yelled at father upon leaving clinic. (emoting)

AP "I lifted weights for a while because I thought maybe if I get muscley..." (compensation)

AP "But there’s a lot more things I’d rather worry about than getting big." (acceptance/selective
devaluing)
AP Called mother to discuss results of clinic visit and the way he was feeling. (seeks support)

AV Re: father’s height: "Not m small cuz we’re the same height." (minimizing)
AV Re: teasing in the sixth grade: '1 blocked it out of my head." (avoiding/denying)
AV Re: teasing in the sixth grade: Became "extremely aggressive." (emoting)

AV "I have to put up with it [being short], which really sucks." (resigned acceptance)

AP "1 don’t think I’m little on the inside. I know a lot of other people who are little on the
inside. " (positive self-talk)

AV "Because of all the weird treatment I got, I began to think it was something I did. I thought
it was my fault." (self-blame)

AP "But as I said before, at least I know I’m not ugly and stuff. I’m sure some ugly people
wouldn’t mind being shorter." (positive reappraisal)

 

 

 

 

5.) Positive Impact: 0 6.) Negative Impact: 3 7.) Comments (e.g., other neg):

140

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