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Letters to the Editor |
University at Buffalo, State University of New York and Children’s Hospital of Buffalo Buffalo, New York 14222
We are concerned that Sartorio, Saraifoger, and Molinari have apparently misinterpreted a finding of our study pertaining to the relationship between adult height and psychological adaptation in a sample of formerly treated childhood-onset growth-hormone deficient (GHD) patients. In our relatively large and complete sample (n = 140), we reported that adult height was, by and large, unrelated to psychological outcomes. [The mean adult (final) height for the sample was -1.5 SD.] In our manuscript, we hastened to underscore that this lack of statistical relationship should not be interpreted as suggesting that GH therapy was ineffective in benefiting the patients. Given the research design we employed (cross-sectional follow-up), we have no conclusive way of knowing how our sample of former patients would have been functioning as adults had they not received GH. It is obvious to us, however, that without treatment, most of these patients would have achieved an extremely limited adult height, which would have constituted a physical disability by challenging the individual’s functional independence. On the other hand, it does not follow from this statement that variability in psychological outcomes is dependent upon adult heights that fall more closely within the normal range. We did not observe such a relationship, nor have other investigators (1, 2), including Sartorio and colleagues (3). Moreover, the research cited by Sartorio et al. in their letter (4) does not provide evidence supporting the conclusion that "GH-induced achievement of full genetic potential seems also important in influencing the quality of life in adults with child-onset GHD ..." In that report of only 8 patients, the mean adult height attained after GH therapy was 146.1 cm, which, by our estimate, is equal to a height SD score of less than -4 SDs, a very poor height outcome. One cannot conclude from that limited study that individuals achieving a more normal adult height (-1.5 SD in the case of our study) are destined to experience a poor quality of life even though they have not achieved their "full genetic (height) potential."
It also appears that Sartorio, Saraifoger, and Molinari are concerned that our findings might be interpreted by some as indicating that there is no benefit to child-onset GHD patients of continuing therapy into adulthood. Although our study (5) suggests that the quality-of-life of former patients is comparable to that of healthy same-sex siblings (and, therefore, this criterion should probably not be used as a rationale for continuing GH therapy), we gathered no data pertaining to the various metabolic parameters that are purportedly influenced by GH in adulthood. We are thus in total agreement with Sartorio and colleagues when they encourage consideration of these metabolic effects when arriving at a decision of whether or not GH treatment should be continued in adulthood.
Finally, we disagree with the conclusion that Sartorio et al. have drawn from their own study of the psychological benefits of GH treatment in adults with childhood-onset GHD (4). In that report, eight adults were studied before and after 6 months of GH therapy. Significant improvements in several parameters of psychological functioning were observed, and performance again deteriorated 6 months after withdrawal of hormone replacement. Although such temporal correspondence between a treatment and clinical effect is a necessary condition for statements regarding therapeutic efficacy, it is not sufficient. Without the presence of a placebo arm to the research design, conclusions regarding the psychological benefits of GH therapy in adulthood must remain tentative. Recent findings from a much larger, placebo-controlled study of GH replacement in adults with either child-onset or adult-onset GHD suggests that only the latter group exhibited benefits to their psychological functioning (6). We also believe it is inappropriate to draw conclusions regarding the benefits of continuing GH therapy in adulthood from an unrepresentative group of formerly-treated patients whose adult height was so poor (<-4 SD). It is understandable that individuals with such a pathologic adult height would experience greater psychosocial stressors and a more negative body image than individuals who, as a group, had achieved an adult height falling within the normal range (i.e. -1.5 SD, as in our study).
Footnotes
Address correspondence to: David E. Sandberg, Ph.D., Pediatric Psychiatry, Children’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222; e-mail:dsandber@acsu.buffalo.edu.
Received September 9, 1998.
References
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