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Self-Esteem in Children and Adolescents with Growth Hormone Deficiency


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Background: The aim of this study was to assess self-esteem in children and adolescents with growth hormone deficiency and to establish the factors influencing self-esteem in children and adolescents with growth hormone deficiency. Methods: This cross-sectional study was carried out on 26 children and adolescents, aged 8 to 18, with a total growth hormone deficiency. The Cooper Smith self-esteem inventory was used in this study. Results: Patients with growth hormone deficiency had low self-esteem in more than 50% of the cases. Among the studied factors influencing the self-esteem, such as school performance, disturbance in parent-child and peers-child relationships, perceived by parents, and parents’ acceptance of the illness, there was a correlation in most of the subscales. Conclusions: Growth hormone impaired children and adolescents require psychological counseling and comprehensive care.
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Iran J Pediatr. In Press(In Press):e4617.
Published online 2018 November 21.
doi: 10.5812/ijp.4617.
Research Article
Self-Esteem in Children and Adolescents with Growth Hormone
Héla Ayadi 1, Leila Cherif 1, Imen Hadjkacem 1, Wiem Kammoun1, *, Khaoula Khemakhem 1, Souhel
Khemekhem 1, Yousr Moalla1, Thouraya Kammoun2, Mongia Hachicha 2and Farhat Ghribi1
1Child Psychiatry Department, Hedi Chaker University Hospital, Sfax, Tunisia
2Pediatric Department, Hedi Chaker University Hospital, Sfax, Tunisia
*Corresponding author: Child Psychiatry Department, Hedi Chaker University Hospital, Road El Ain 0.5 Km, Sfax, Tunisia. Tel: +216-58373722, Fax: +216-74298200, Email:
Received 2015 November 05; Revised 2016 September 17; Accepted 2016 September 20.
Background: The aim of this study was to assess self-esteem in children and adolescents with growth hormone deficiency and to
establish the factors influencing self-esteem in children and adolescents with growth hormone deficiency.
Methods: This cross-sectional study was carried out on 26 children and adolescents, aged 8 to 18, with a total growth hormone
deficiency. The Cooper Smith self-esteem inventory was used in this study.
Results: Patients with growth hormone deficiency had low self-esteem in more than 50% of the cases. Among the studied factors
influencing the self-esteem, such as school performance, disturbance in parent-child and peers-child relationships, perceived by
parents, and parents’ acceptance of the illness, there was a correlation in most of the subscales.
Conclusions: Growth hormone impaired children and adolescents require psychological counseling and comprehensive care.
Keywords: Growth Hormone Deficiency, Self-Esteem, Children, Adolescents
1. Background
The literature predominantly supports the view that
chronic diseases assume the management of a new self-
representation, and that healing is an active construct and
a learning process to live with limits. It represents a dis-
ruption of self-representation and feelings of invincibility,
as well as defensive management reconsideration (1,2). In
fact, disease is the first threat to this narcissism that cre-
ates difficulty in the sick or mutilated body investment.
In general, disease may affect the physical and psycholog-
ical integrity. It also leads to a weak position and a de-
pendency on doctors, on cares with loss of autonomy, on
relatives, and on all the life factors (3,4). In this context,
growth hormone deficiency (GHD) constitutes the clear-
est demonstration of chronic disease psychological reper-
cussions. As a matter of fact, GHD will inevitably lead to
a growth delay in a critical period of the development.
Furthermore, treatment with synthetic growth hormone
(GH) is often slow and requires regular daily injections. All
these may negatively affect child and adolescents psychol-
ogy. These psychological disturbances could involve dis-
turbed body image, social isolation, anxious and depres-
sive manifestations, impaired quality of life, and low self-
esteem (3,5). As far as self-esteem, in particular, is con-
cerned, it seems controversial whether there is a relation-
ship between short stature in children with GHD and low
self-esteem or not. This divergence may be due to that self-
esteem has commonly been assessed by the children’s par-
ents while a few studies have been conducted based on
questionnaires signed by the children themselves (6). It
is noteworthy to mention that self-esteem has two contin-
gencies: an intrinsic contingency where self-esteem is af-
fected by whether one’s actions are self-congruent and con-
ducive to a personal growth, and an extrinsic contingency
corresponding to social, school, and familial factors (7).
2. Objectives
The present study evaluates the self-esteem in children
and adolescents with GHD via a self-report questionnaire,
not exclusively based on parental perceptions. Moreover,
since surveys carried out in Tunisia have primarily focused
on the organic side of GHD, and as the self-esteem has yet
to be explored, our study aimed to emphasize the relation-
ship between GHD and low self-esteem, and to reveal influ-
encing factors that should be dealt with in order to relieve
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Ayadi H et al.
those children from this psychological burden.
3. Methods
A cross-sectional comparative study was conducted on
two groups of children and adolescents during a period of
one year (January to December 2012).
3.1. Subjects
The first group included 30 children and adolescents,
aged between 8 and 18 years, affected by a total deficit
in GH. All these patients were being treated by the syn-
thetic GH (6 days a week in 23 cases and 7 days a week in
7 cases) and followed in the pediatric department of the
Hedi Chaker University Hospital of Sfax. The second group
included 60 children and adolescents examined in a com-
munity clinic in Sfax for benign acute medical condition
(flu and so on). Children and adolescents of the two groups
were matched for age, sex, and socioeconomic status. The
mean age of each group was 13 years (±3.16). The eth-
nic composition was the same in both groups (100% Cau-
casian). In the present study, we included all children and
adolescents aged between 8 and 18 years, being followed
for a total deficit of GH confirmed by two GH simulation
tests (Insulin and Propranolol glucagon stimulation tests).
The diagnosis of GHD was based on GH value of less than
5 ng/mL. On the other hand, patients presenting a staturo-
ponderal delay, secondary to another pathology (celiac dis-
ease, Turner syndrome, chronic visceral disease, Crohndis-
ease, renal insufficiency, tubulopathy, and metabolic dis-
ease), patients aged under 8 or more than 18, and patients
presenting a GHD untreated by the biosynthetic GH were
3.2. Assessments
For each patient included and his parent (father or
mother), a clinical interview based on a predetermined for-
mat was done by a child and adolescent psychiatrist. The
interviews were held in an atmosphere of confidentiality
in an examination room in the pediatric department of the
Hedi Chaker University Hospital of Sfax.
3.3. Instruments
These interviews followed a predetermined format to
disclose the socio-demographic information (age, school
performance, and parents’ level of education) and semi-
ological data (size at diagnosis, age at beginning of treat-
ment, family relationship, peers-child relationship, cogni-
tive disturbances such as sluggishness, attention deficit
disorder, and memory disturbances, GHD whether associ-
ated with thyroid-stimulating hormone deficiency (TSHD)
or not, growth retardation recognition whether by parents
or physicians, and parents acceptance of the illness). The
written parental consent to participate in this study was re-
Self-esteem was measured by Coopersmith Self-
Esteem-Inventory (SEI). The Coopersmith SEI is a self-report
instrument of 58 items to which each subject responds
“like me” or “unlike me.” The present study used the Arabic
translation of the Coopersmith SEI, in its school form for
the ages 8-15. The Coopersmith SEI was developed through
research to assess attitude toward oneself in general and
in specific contexts. It consists of four subscales designed
to assess the perception of self (General self-subscale: 26
items), peers (Social self-peer subscale: 8 items), parents
(Home-parents subscale: 8 items), and school (School-
academic subscale: 8 items). The total self-score was
computed by summing up the four subscale scores. The
sum of the four subscales represented the total SEI score
ranging between 0 and 100. Children or adolescents have
a positive self-image if scores are in general subscale >
18.64, social subscale > 5.67, familial subscale > 4.92,
school subscale > 4.12, and total subscale > 33.35. The
subscales were grouped into two contingencies: intrinsic
contingency represented by the general subscale, and
extrinsic contingency encompassing social, familial, and
school-academic subscales.
3.4. Statistics
Statistical analysis was performed by using the SPSS sta-
tistical package, version 11.0. The Chi-square test was used
to compare the frequencies and the t-test to compare the
means. Rejection of the Null hypothesis was set at P < 0.05.
4. Results
4.1. Sample Identification
The mean age of our patients at the time of diagnosis
was six (ranging from 3 to 14 years) while the mean age of
our patients at the time of the study was 13 (ranging from
8 to 18 years). 46% of the patients were aged 12 years or less
and the remaining patients (54%) were aged over 12. The
sample was male-dominated with a sex ratio of 2.3. 23% of
the cases were from rural areas while 77% were from urban
areas. In the present study, the inbreeding rate was 36.7%. A
parental small size was found to be 6.7% among fathers and
13.3% among mothers. The majority of our patients repre-
senting 90% attended school: 60% were at the basic school
level while 30% were at the secondary school level. Two of
our patients (6.7%) received vocational training. Only one
patient (3.3%) had never attended school. The grade repeti-
tion rate was 33.3% although 80% had a mid to good school
2Iran J Pediatr. In Press(In Press):e4617.
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Ayadi H et al.
Table1. Means and Pathological Rates in SEI
GHD Group Control Group P Value
Home-parents subscale
Mean ±SD 5.1 ±1.44 5.7 ±1.67 0.81
Low self-esteem, % 40 18 0.026
School-academic subscale
Mean ±SD 4.77 ±1.56 5.43 ±1.63 0.067
Low self-esteem, % 54 26 0.01
Social self-peer subscale
Mean ±SD 5.1 ±1.56 5.2 ±1.3 0.75
Low self-esteem, % 60 56 0.76
General subscale
Mean ±SD 14 ±4.7 18.1 ±5.2 0.001
Low self-esteem, % 84 33 0.000
Mean ±SD 29 ±7.1 34.6 ±7.5 0.001
Low self-esteem, % 80 33 0.000
Abbreviations: GHD, growth hormone deficiency; SEI, self-esteem inventory.
performances. The results of the different hormonal explo-
rations revealed an isolated GHD rate of 76.6% and an asso-
ciated GHD with TSHD rate of 23.4%. All the patients were
small sized.
4.2. Self-Esteem
Table 1 compares the means and pathological rates in
SEI in the two studied groups across the studied subscales.
Tables 2,3,4,5, and 6show the correlations between in-
dividual and illness-related factors and self-esteem respec-
tively in total, general, school, social, and familial subscale.
5. Discussion
In this study, patients with GHD had low self-esteem on
the five subscales: familial, school, social, general, and to-
tal. The differences were significant in all subscales except
the social subscale.
Several studies revealed a self-esteem decline in pa-
tients with GHD (8,9). In fact, the physical performances
decline in these patients may result in the decline in self-
esteem (10,11). Some studies demonstrated that patients
with GHD had a comparable self-esteem decline with those
having chronic disease such as diabetes or asthma (12,13).
Nevertheless, the link between GHD and self-esteem de-
cline is not unanimously accepted (14,15). For some au-
thors, it is rather the child personal perception of his size
that influences self-esteem than the real size (8,15).
Table2. Self-EsteemCorrelated Factors in Children and Adolescents with GHD in the
Total Subscale
Self-Esteem in the TotalSubscale High, % Low, % P Value
School performance 0.01
Low 0 21.73
Mid to high 100 78.26
GHD 0.005
Isolated 87.5 33.33
Associated with TSHD 12.5 66.66
Parents acceptance of the illness 0.01
Yes 83.33 100
No 16.66 0
Disturbance in parent-child
relationship perceived by parents
No 66.66 5.88
Yes 33.33 94.11
Abbreviations: GHD, growth hormone deficiency; TSHD, thyroid-stimulating
hormone deficiency.
Table3. Self-EsteemCorrelated Factors in Children and Adolescents with GHD in the
General Subscale
Self-Esteem in the General Subscale High,% Low,% P Value
Age 0.02
12 72.72 31.57
> 12 27.27 68.42
School performance 0.01
low 14.28 21.73
Mid to high 85.71 78.26
GHD 0.03
Isolated 87.5 33.33
Associated with TSHD 12.5 66.66
Parents acceptance of the illness 0.02
Yes 83.33 29.16
No 16.66 70.83
Disturbance in parent-child
relationship perceived by parents
No 50 29.16
Yes 50 70.83
Disturbance in parent-child
relationship perceived by child
No 40 44
Yes 60 56
Abbreviations: GHD, growth hormone deficiency; TSHD, thyroid-stimulating
hormone deficiency.
Iran J Pediatr. In Press(In Press):e4617. 3
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Ayadi H et al.
Table4. Self-Esteem Correlated Factors in Children and Adolescents with GHD in the
School-Academic Subscale
Self-esteem in the school subscale High, % Low,% P Value
School performance 0.03
Low 7.14 26.66
Mid to high 92.85 73.33
Growth retardation recognition 0.01
Parents 7.14 37.5
Physicians 92.85 62.5
Abbreviation: GHD, growth hormone deficiency.
Table5. Self-EsteemCorrelated Factors in Children and Adolescents with GHD in the
Social Self-Peer Subscale
Self-esteem in the social subscale High, % Low, % P Value
Sex 0.03
Male 90.90 57.89
Female 9.09 42.10
School performance 0.05
Low 15.38 23.52
Mid to high 84.61 76.47
Cognitive disorders 0.03
Yes 33.33 61.11
No 66.66 38.88
Father’s level of education 0.05
Illiterate/primary 41.66 77.77
Secondary 58.33 22.22
GHD 0.05
Isolated 83.33 72.22
Associated with TSHD 16.66 27.77
Disturbance in parent-child
relationship perceived by parents
No 66.66 27.77
Yes 33.33 72.22
Abbreviations: GHD, growth hormone deficiency; TSHD, thyroid-stimulating
hormone deficiency.
5.1. Factors Influencing Self-Esteem
GHD associated with TSHD type was significantly cor-
related with low self-esteem, particularly in the total (P =
0.05), general (P = 0.03), and social (P = 0.05) subscales.
This is in line with the results of several studies (1,16,17).
In fact, the association of two pathologies and its repercus-
sions, as well as treatment multiplication, could negatively
affect self-esteem.
In this study, relationship disturbances between child
and father were correlated with low self-esteem in total,
Table6. Self-Esteem Correlated Factors in Children and Adolescents with GHD in the
Familial Subscale
High, % Low, % P Value
Age at the beginning of treatment 0.02
< 8 66.66 25
8 33.33 75
Size at diagnosis 0.05
-2 SD, -3 SD 11.11 41.66
< -3 SD 88.88 58.33
Disturbance in peers-child relationship
perceived by peers
No 61.11 8.33
Yes 38.88 91.66
Disturbance in parent-child
relationship perceived by parents
No 64.70 7.69
Yes 35.29 92.30
Abbreviation: GHD, growth hormone deficiency.
general, social, and familial subscales. A harmonious re-
lationship between the child and his father is associated
with better psychological adjustment for children. The fa-
ther could influence indirectly his child physical health
and well-being: global social competence, the spirit of ini-
tiative on the social level, social maturity, and capacity to
establish contacts with others (3,18). Moreover, the father
is involved in building the child personality, by fostering
autonomy and self-sufficiency necessary to maintain a bal-
anced affective life, and by enhancing self-confidence use-
ful for the upcoming competences, which may be ham-
pered by the illness (2,3).
In the present study, peers relationship disturbances
were correlated with low self-esteem in the familial sub-
scale (P = 0.01). This is in line with Pendley et al. (19) and
Seiffge-Krenke (20) studies.
Pendley et al. (19) demonstrated that daily treatment is
the main source of patients’ concerns, particularly in ado-
lescence. Indeed, adolescent feels deprived of his liberty.
Thus, this freedom infringement caused by the disease and
this feeling of being different from others are the factors
that influence self-esteem. Seiffge-Krenke (20) noticed that
because of their chronic disease, many patients feel com-
pelled to live a restrictive social life. Youths who are enter-
ing their teens seek to care for themselves, thus acquiring
their autonomy. At this age, making comparisons between
peers have a crucial role, and sick adolescents experience
feelings of worthlessness and rejection. All these feelings
have a negative impact on self-esteem (1).
In the present study, self-esteem in the general subscale
4Iran J Pediatr. In Press(In Press):e4617.
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Ayadi H et al.
was significantly more negative in adolescence (age > 12
years old) (P = 0.02). In the same way, Atkin and Ahmad
(21) noted that some adolescents, generally at 12, ask the
question “why me?” when they compare their lives with
their friends’ lives, as the disease imposes serious life re-
strictions. These adolescents deal with the risk to become
withdrawn, to develop complex, to experience social rela-
tionship disruptions and consequently, to an unbalance
and negative self-image. Besides, adolescents, in general,
tend to seek independence and autonomy, which could be
hindered by their illness.
In the present study, the late age at the beginning
of treatment was significantly correlated with low self-
esteem in the familial subscale (P = 0.02). In this sense, Ross
et al. (16) demonstrated the impact of late-onset treatment
on self-esteem. Marcelli (22) evidenced that body map
damage, or rather the “sense of self” damage in its broad-
est sense, depends on seriousness, duration, and nature of
the disease. Concerning treatment, Alvin et al. (1) noticed
that self-image is influenced by the number of medications
and by the number of daily medical intake. The increased
number of daily injections could help relieve psychologi-
cal stress and foster compliance.
As outlined in the present study, there was a significant
correlation between female sex and low self-esteem in the
social subscale (P = 0.03). In fact, in our culture, being a
woman is generally associated with the female stereotyped
social roles as spouse and mother. Regrettably, a healthy
girl will be more likely to get married and to have children
than a sick girl. Thereby, they would probably be more ful-
filled socially. According to the study of Chaplin carried out
on prepubertal children with GHD, girls have a lower self-
esteem than boys do.
A significant correlation was demonstrated between
growth retardation between -2 DS and -3 DS and low self-
esteem (P = 0.05). This parallels the data of the literature
demonstrating that short children have an impaired self-
concept as expressed by feelings of unpopularity and dis-
satisfaction and that they tend to view themselves less fa-
vorably than do their taller peers (23).
5.2. Conclusion
Overall, the results of our investigation contributed to
the current debate over the relationship between GHD in
children and adolescents and self-esteem and provided evi-
dence for low self-esteem in GH impaired children and ado-
lescents alongside several other studies. It also revealed
several factors influencing the self-representation of these
patients. This highlights the importance of early screening
and psychological care to avoid the emergence of a charac-
terized mental disease.
Thus, the findings presented here do not extend to the
psychological benefits of GH treatment. In order to fur-
ther elucidate this fact, there is a clear need for a controlled
study of the GH treatment effect over a Tunisian sample.
Authors’ Contribution: Study concept and design: Héla
Ayadi, Leila Cherif, Imen Hadjkacem, Wiem Kammoun,
Khaoula Khemakhem and Souhel Khemekhem; acquisi-
tion of data: Héla Ayadi and Souhel Khemekhem; anal-
ysis and interpretation of data: Héla Ayadi, Leila Cherif,
Wiem Kammoun and Souhel Khemekhem; drafting of the
manuscript: Héla Ayadi, Leila Cherif, Imen Hadjkacem,
Wiem Kammoun, Yousr Moalla and Farhat Ghribi; critical
revision of the manuscript for important intellectual con-
tent: Héla Ayadi, Leila Cherif, Khaoula Khemakhem, Yousr
Moalla, Thouraya Kammoun, Mongia Hachicha and Farhat
Ghribi; statistical analysis: Héla Ayadi, Leila Cherif and
Souhel Khemekhem; administrative, technical, and mate-
rial support: Yousr Moalla, Thouraya Kammoun, Mongia
Hachicha and Farhat Ghribi; study supervision: Héla Ayadi,
Leila Cherif, Yousr Moalla, Thouraya Kammoun, Mongia
Hachicha and Farhat Ghribi.
Conflict of Interests: The authors report no actual or po-
tential conflict of interests.
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The purpose of this paper is to propose a French valid psychometric tool for the assessment of self-esteem in the physical domain, adapted from the Physical Self-Perception Profile (Fox and Corbin, 1989). The French version consists of 6 subscales. The first one assesses general self-esteem, and the second one is devoted to the measurement of general overall physical self-worth. 4 subscales are designed to assess perceptions within specific subdomains of the physical self, physical condition, sport competence, attractive body and physical strength. 168 subjects (study 1) responded to our 30 items inventory. A principal components factor analysis with orthogonal rotation confirmed factorial structure hypothesis. However, the deletion of 5 items increased the internal consistency of subdomains. Hierarchical organisation of self perception of our 25 items experimental inventory tested with corelational and confirmatory analyses (LISREL) showed specific aspect for the attractive body’s subscale. Study 2 proved the fidelity of this French experimental version of the PSPP.
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To evaluate effects of growth hormone (GH) treatment on behaviour and psychosocial characteristics in short-stature children. 99 referred prepubertal non-familiar short-stature children (32 GH deficiency; 67 idiopathic short stature) aged 3-11 years, randomized to fixed or individual GH doses and their parents completed questionnaires (Child Behaviour Checklist, Birleson Depression Self-Report Scale, Abbreviated Parent-Teacher Questionnaire, I Think I Am, Well-Being Visual-Analogue Scales for Short-Stature Children) at baseline (BL) and after 3, 12, and 24 months. At BL, children showed higher levels of internalizing behaviour (p < 0.001), lower levels of externalizing behaviour (p < 0.006) and self-esteem (p < 0.001) compared to reference values. During GH treatment, behavioural measures (p < 0.001) and depression (p < 0.01) changed towards the mean of the population within the first 3 months and remained improved to 24 months. Self-esteem improved at all time points (p < 0.001), and in all subgroups, as did well-being dimensions stability and mood (p < 0.05). Multiple regression analysis showed that greater improvements were related to lower BL value, height gain, higher maximal GH value, being older, and being male. On GH treatment, prepubertal short children significantly improved on behavioural, depression, and psychosocial evaluations over a 2-year period of GH treatment. Most change occurred within the first 3 months, which highlights this short period as important not only for growth and metabolic changes but also for behaviour and psychosocial improvements following GH treatment.
Introduction Le déficit en GH (GHD) n’entraîne pas de retentissement sur le développement psychomoteur mis à part les patients ayant des malformations neurologiques responsables d’handicaps mentaux, dans les cas d’hypothyroïdie non ou tardivement traitée ou d’hypoglycémies itératives. Objectif Évaluer le développement psychomoteur et le retentissement psychologique des enfants présentant un GHD. Population, méthodologie Étude prospective concernant 120 enfants GHD. Tous les patients ont bénéficié d’une évaluation psychologique (épreuve de GOOD NOUGH) et d’un suivi. Résultats L’âge mental moyen des patients correspond à leur âge moyen chronologique : 8,3 ± 2,08 ans vs 7,8 ± 4,2 ans (DNS). Le QI moyen est normal : 97,45 ± 17,06. Celui-ci est élevé dans 5 cas. Il existe un retard mental dans 10 % en rapport avec : une hypothyroïdie tardivement traitée dans n : 5 (4,1 %) ; des hypoglycémies itératives méconnues associées à des anomalies endocrâniennes neurologiques dans n : 4 (3,3 %) ; des malformations neurologiques intracrâniennes dans n : 2 (1,6 %) ; des lésions neurologiques post-radiques dans 1 cas (0,8 %). Il existe des troubles psychiques chez les plus âgés, n : 20 ; complexe d’infériorité et repli sur soi en réaction aux hostilités et moqueries des sujets de même âge, n : 15 ; sentiment de rejet de la part des siens, n : 5. Conclusion Le développement intellectuel est normal chez l’enfant GHD. Une inadaptation sociale et des problèmes neuropsychiques peuvent être observés, liés à la petite taille et non pas au déficit hormonal.
Growth hormone (GH) affects all organ systems and several studies have also indicated an influence on health related quality of life (QoL). Assessment of QoL is therefore considered as one of several valid indicators of whether or not treatment with GH is beneficial. Two main types of QoL measures are generally used: disease-specific and generic. A combination of the two is generally advocated as they seem to be complementary. Methodologically, questionnaires must be correctly validated in the relevant context of language and a sufficient population based reference group. In this review, the previously published studies on the effects of GH replacement therapy on QoL in adults will be scrutinized. Although many of the studies on the influence of GH replacement on QoL assessment are either having a too short follow-up period, are uncontrolled, or using supra-physiological GH doses or inappropriate QoL instruments, there is a growing body of evidence for impaired QoL in GH deficient patients with improvement or normalisation after GH replacement.
In clinical practice, non-compliance is an often unrecognised or frustrating reality, which physicians find difficult to accept or deal with. Possible determinants of adolescents' level of compliance may be divided into demographic factors, patient and family characteristics, aspects of the illness and treatment regimen, and quality of the patient-doctor relationship. Compliance should be viewed as a reflexion of the experience of chronic illness as well as the expression of specific adolescent developmental issues. Practical guidelines are proposed.
This qualitative paper explores the strategies and resources young people use to cope with sickle cell disorder or thalassaemia major, two haemoglobin disorders with serious implications for health and survival. By focusing on coping strategies, we explore how young people attempt to take control over their lives. The respondents, largely of South Asian and African Caribbean origin, aged between 10 and 19 years, valued maintaining a 'normal' life and struggled to achieve this normalcy. Strategies were employed to minimise difference from peers but these strategies remained vulnerable. Coping occurred in a dynamic space, involving negotiation and engagement with both personal and structural factors. Threats to normalcy did not always reside in the condition; life transitions, changes in social relationships and racist, disablist or sexist marginalisation also threatened coping strategies.
To determine the psychosocial effects of short stature, we administered a battery of psychologic tests to 24 children (ages 6 to 12 years) with constitutional short stature. Their results were compared to those of a group of 23 healthy children with normal stature matched for age, IQ, sex, and socioeconomic status. The short children had significantly higher scores on parental ratings of behavioral difficulties, especially somatic complaints, social withdrawal, and schizoidal tendencies. There were also indications of impaired self-concept as expressed by feelings of unpopularity and dissatisfaction. Parental responses suggested a tendency to set less clear limits on behavior, but not necessarily toward overprotectiveness. Parents of short children also gave responses indicating poorer communication and cooperation among family members. In contrast to recent studies of growth hormone-deficient children, in which no maladjustment surfaced, these results indicate that children with constitutional delay have characteristic behavioral difficulties.