A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa.

OBJECTIVE: To compare the effectiveness of behavioral family systems therapy (BFST) with that of ego-oriented individual therapy (EOIT) as treatments for adolescents with anorexia nervosa. METHOD: Thirty-seven adolescents meeting DSM-III-R criteria for anorexia nervosa were randomly assigned to receive BFST or EOIT, in addition to a common medical and dietary regimen. In BFST, the family was seen conjointly, the parents were placed in control of the adolescent's eating, distorted beliefs were targeted through cognitive restructuring, and strategic/behavioral interventions were used to change family interactions. In EOIT, the adolescent was seen individually, with an emphasis on building ego strength and uncovering the dynamics blocking eating; parents were seen collaterally. Measures administered before, after, and at 1-year follow-up tapped body mass index, menstruation, eating attitudes, ego functioning, depression, and family interactions. RESULTS: BFST produced greater weight gain and higher rates of resumption of menstruation than EOIT. Both treatments produced comparably large improvements in eating attitudes, depression, and eating-related family conflict, but very few changes occurred on ego functioning. CONCLUSIONS: BFST and EOIT proved to be effective treatments for adolescents with anorexia nervosa, but BFST produced a faster return to health.

Behavior change after growth hormone treatment of children with short stature.

OBJECTIVES: To measure the prevalence of behavioral and learning problems among children with short stature and to assess the effect of growth hormone (GH) treatment on such problems. STUDY DESIGN: A total of 195 children with short stature (age range 5 to 16 years, mean age 11.2 years) were tested for intelligence, academic achievement, social competence, and behavior problems before beginning GH therapy and yearly during 3 years of treatment. Children were classified as having growth hormone deficiency (GHD) when GH responses to provocative stimuli were <10 ng/mL (n = 109) and as having idiopathic short stature (ISS) when >10 ng/mL (n = 86). A normal-statured matched comparison group was tested at the baseline only. RESULTS: Seventy-two children in the GHD group and 59 children in the ISS group completed 3 years of GH therapy and psychometric testing. Mean IQs of the children with short stature were near average. IQs and achievement scores did not change with GH therapy. Child Behavior Checklist scores for total behavior problems were higher (P < .001) in the children with short stature than in the normal-statured children. After 3 years of GH therapy these scores were improved in patients with GHD (P < .001) and ISS (P < .003). Also, there was improvement in the scores of children in the GHD group in the internalizing subscales (withdrawn: P < .007; somatic complications, P < .001; anxious/depressed, P < .001) and on the 3 components of the ungrouped subscales (attention, social problems, and thought problems, each P = .001). Larger effects were observed in the GHD group than in the ISS group. CONCLUSIONS: Many referred children with short stature have problems in behavior, some of which ameliorate during treatment with GH.

The psychological consequences of Turner syndrome and review of the National Cooperative Growth Study psychological substudy.

OBJECTIVE: To present longitudinal data on the psychological profile of a cohort of girls with and without Turner syndrome (TS) treated for 3 years with growth hormone (GH). METHODS: Among a sample of 283 children with short stature, 37 girls with TS were recruited at 27 US medical centers. Of the original cohort, 22 girls with TS, 13 girls with isolated growth hormone deficiency (GHD), and 12 girls with idiopathic short stature were followed through 3 years of GH therapy. All were school-age, were below the 3rd percentile for height, had low growth rates, and were naive to GH therapy. Psychological tests (the Wide Range Achievement Test and the Slosson Intelligence Test) were administered to the clinical groups within 24 hours of their first GH injection and yearly thereafter. Control subjects were 25 girls with normal stature matched for age and socioeconomic status, who were tested only at baseline. One parent of each subject also completed the Child Behavior Checklist for that subject. RESULTS: At baseline, the clinical groups had more internalizing behavioral problems, had fewer friends, and participated in fewer activities than did the control subjects. The groups did not differ in mean IQ or academic achievement, but the TS group did have more problems in mathematics achievement. Height and growth rate significantly increased in the clinical groups over the 3 years of GH therapy, but IQ and achievement scores did not. Significant linear reductions were noted in both Internalizing and Externalizing Behavior Problems after GH treatment, with the TS group having fewer behavior problems before and after GH treatment than did the GHD-idiopathic short stature group. Decreases in specific Child Behavior Checklist subscales, including attention, social problems, and withdrawal, also were seen in the clinical groups after GH therapy. CONCLUSIONS: The comprehensive treatment of girls with TS should include educational and behavioral interventions in addition to traditional medical therapies.

My mother caused my illness: the story of a survivor of Münchausen by proxy syndrome.

OBJECTIVE: Münchausen by proxy syndrome (MBPS) is a form of child abuse in which a parent fabricates or produces illness in a child. Although the medical consequences of MBPS have been well described, there is no detailed published account of what it was like to grow up in a family where the mother systematically induced serious illness. This article describes one victim's childhood experiences. METHODS: The medical history was obtained from a review of the original medical records, notes from the primary physician, discussions with two physicians who provided treatment, and several meetings with the victim and the victim's therapist. RESULTS: This article chronicles the actual experiences of an MBPS victim through 8 years of medical abuse at the hands of her mother, reveals the victim's account of what happened to her, describes what her family was like, details the long-term consequences on emotional and physical development, identifies the factors that influence recovery, and details the impact on family relationships. CONCLUSIONS: Child maltreatment and MBPS need to be part of the differential diagnosis when the clinical picture is atypical or does not appear medically plausible. The consequences of MBPS are psychological and physical and impact the entire family. Suggestions to assist heath care providers recognize, assess, and report cases of suspected MBPS are provided.

Links between growth hormone deficiency, adaptation and social phobia.

Children referred for growth hormone (GH) treatment have increased school achievement problems, lack appropriate social skills and show several forms of behavior problems. A multicenter study in the United States has revealed that many GH-impaired children exhibit a cluster of behavioral symptoms involving disorders of mood and attention. Anxiety, depression, somatic complaints and attention deficits have been identified. These symptoms decline in frequency over a period of 3 years, beginning shortly after GH replacement therapy is started. Many of the patients who have received GH and had good growth responses show lower than average quality of life in young adulthood after treatment is completed. GH-deficient adults placed on GH therapy report improvement in psychological well-being and health status, suggesting that GH might have a central neuroendocrine action. Among a group of adults who were GH deficient as children, we find a high incidence of social phobia, a psychiatric disorder linked to GH secretion and usually accompanied by poor life quality. An ongoing study of non-GH-deficient short individuals suggests that short stature is not the cause of this outcome. We conclude that the origins of psychiatric comorbidities, such as social phobia and depression, in GH deficient adults are likely to be neuroendocrine as well as psychosocial.

Family versus individual therapy for anorexia: impact on family conflict.

This study evaluated the impact on family relations of behavioral family systems therapy (BFST) versus ego-oriented individual therapy (EOIT) as treatments for adolescents with anorexia nervosa. Twenty-two adolescents meeting DSM-III-R anorexia nervosa criteria were randomly assigned to receive approximately 16 months of either BFST or EOIT along with a common medical and dietary regimen. BFST emphasized parental control over eating, cognitive restructuring, and problem-solving communication training. EOIT emphasized building ego strength, adolescent autonomy, and insight. Measures including body mass index, self-reported general and eating-related conflict, and observed general and eating-related communication. Both treatments produced significant reductions in negative communication and parent-adolescent conflict, with some differences between condition and between eating and non-eating related measures; the improvements in eating-related conflict were maintained at a 1-year follow-up. The study demonstrated that structured therapies for adolescent anorexia do impact family relations, even when the family is never seen as a unit during the therapy.

Family therapy versus individual therapy for adolescent females with anorexia nervosa.

Behavioral family systems therapy (BFST) was compared with ego-oriented individual therapy (EOIT) in a controlled, random-assignment investigation involving 22 young adolescents with anorexia nervosa. Each adolescent and her parents received approximately 16 months of outpatient therapy along with a common medical and dietary regimen. BFST emphasized parental control over eating and weight gain, coupled with cognitive restructuring and problem-solving communication training. EOIT emphasized building ego strength, adolescent autonomy, and insight into the emotional blocks to eating. BFST produced greater change on body-mass index than did EOIT, but both treatments produced comparable improvements on eating attitudes, body shape dissatisfaction, interoceptive awareness, depression/internalizing psychopathology, and eating-related family conflict. The implications of these results for the clinician who treats adolescents with anorexia nervosa are discussed.

Academic achievement and psychological adjustment in short children. The National Cooperative Growth Study.

Limited information is available on the educational and behavioral functioning of short children. Through 27 participating medical centers, we administered a battery of psychologic tests to 166 children referred for growth hormone (GH) treatment (5 to 16 years) who were below the third percentile for height (mean height = -2.7 SD). The sample consisted of 86 children with isolated growth-hormone deficiency (GHD) and 80 children with idiopathic short stature (ISS). Despite average intelligence, absence of significant family dysfunction, and advantaged social background, a large number of children had academic underachievement. Both groups showed significant discrepancy (p < .01) between IQ and achievement scores in reading (6%), spelling (10%), and arithmetic (13%) and a higher-than-expected rate of behavior problems (GHD, 12%, p < .0001; ISS, 10%, p < .0001). Behavior problems included elevated rates of internalizing behavior (e.g., anxiety, somatic complaints) and externalizing behavior (e.g., impulsive, distractable, attention-seeking). Social competence was reduced in school-related activities for GHD patients (6%, p < .03). The high frequency of underachievement, behavior problems, and reduced social competency in these children suggests that short stature itself may predispose them to some of their difficulties. Alternately, parents of short, underachieving children may be more likely to seek help. In addition, some problems may be caused by factors related to specific diagnoses.

Growth hormone deficiency in children has psychological and educational co-morbidity.

Growth delay caused by growth hormone deficiency (GHD) is a condition presented with increased frequency to pediatricians. Recent evidence suggests these patients should be evaluated developmentally for behavioral and educational problems. Such assessment would assure a comprehensive approach to treatment and increase the likelihood of a satisfactory outcome in young adulthood. This article briefly reviews what is known about the behavioral and educational difficulties experienced by growth hormone deficient patients. Specific recommendations for educational assessment and anticipatory guidance are presented.

Psychological impact of significantly short stature.

These baseline data confirm that many children with significantly short stature are vulnerable to diverse developmental, social and educational problems, and substantiate the importance of a multidisciplinary treatment approach that includes a comprehensive psychological and medical assessment. The psychological assessment should focus on the early detection of problems in academic achievement and psychosocial development, in order that appropriate educational and counselling interventions can be provided. The paediatrician can also foster a positive relationship with patients and their families to facilitate treatment compliance and improve overall outcome in several ways. These include a simple explanation of the aetiology of the child's short stature and how the diagnosis was made, a review of the treatment protocol that includes information about potential side-effects and suggestions for minimizing conflicts about injections, and an open discussion of prognosis to help families develop realistic expectations. It is further suggested that paediatricians stress that treatment outcome should be assessed in psychological terms, such as increased responsibility, as well as physical growth. These anticipatory interventions will help to ensure that the eventual outcome of comprehensive treatment is an optimally functioning young adult.