Growth hormone (GH) treatment is a paradigm of ?expansive biotechnology,? wherein a biomedical technology originally designed for treatment of disease (GH deficiency; GHD) expanded, with the encouragement of well- intended physicians and support of industry, into treatment of conditions that blur the boundary between disease and variation (idiopathic short stature; ISS), with an estimated potential national cost of $40 billion. In our prior research, parents indicated that concerns about the impact of short stature on psychosocial function, both in childhood and projected into adulthood, have a major influence on their decision to seek medical care for a child's short stature. Yet thus far height has been the primary outcome measure of GH treatment, even though height is a poor predictor of psychosocial adjustment and health-related quality of life (QoL). The long- term goal of this research is to determine what drives better QoL and psychosocial adjustment in youth with short stature. While the prevailing assumption holds that the attainment of increased height directly provides benefit, we hypothesize that the impact of height on QoL and self-esteem is modified by characteristics of the parent and youth to a degree that exceeds the impact from height gain itself, with or without GH treatment. Thus, the proposed longitudinal mixed-methods study will follow for two years youth aged 8-14 years who undergo provocative GH testing in our Growth Center and a parent participant. Using semi-structured interviews and novel quantitative measures, Specific Aim 1 will explore youth and parent perceptions of short stature and its impact on QoL, perceptions and expectations vis-a-vis GH treatment, and decision-making regarding evaluation of short stature and GH treatment, with a focus on the youth's role in decision-making, which has not been studied but is critical in the context of an elective treatment (ISS) that is chronic (years), invasive (daily injections), and carries potential side effects. Using quantitative measures of both QoL and the positive aspects of self-esteem, Specific Aim 2 will describe trajectories of youth QoL and self-esteem for 2 years after provocative GH testing, including youth with GHD, ISS treated with GH, and ISS not treated with GH.
Specific Aim 3 will define specific parent and youth characteristics that modify the relationship of height to QoL and self-esteem for those two years. The research proposed in this application will address a critical gap in our understanding of how patient and parent characteristics alter the potential impact of being short, and transform the currently held, traditional disease model of short stature into a richer framework that includes parent characteristics, parenting styles and youth characteristics as well as height. The proposed work will thereby lay the foundation for future definitive, long-term, randomized controlled trials testing the efficacy of GH or other interventions for short stature that include QoL and psychosocial adjustment as primary outcomes, and enable the field and clinical care to move forward in an evidence-based, value-driven way.

Public Health Relevance

Growth hormone treatment is often sought to improve the quality of life and self-esteem of short children and the adults they become, even though height is a poor marker for psychosocial adaptation and treatment involves years of daily injections with potential side effects and considerable cost.This longitudinal mixed- methods study aims to understand height-related medical decision-making by youth with short stature and their parents, including the role of the youth themselves in that process, as well as to define specific parent and youth characteristics that modify the relationship of height to quality of life and self-esteem. The knowledge gained will provide a critical foundation for future definitive trials of of growth hormone or other interventions in which quality of life, rather than height, is the primary outcome, to enable the management of youth with short stature to develop in an evidence-based, value-driven way.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Lee, Karen
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Children's Hospital of Philadelphia
United States
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