Short stature is statistically defined as a height standard deviation score <-2 or <3rd percentile for their age. However, children even who have average heights are visiting pediatric specialty clinic setting to seek evaluation for short stature. Previous studies reported that only 18%-30% children who visited hospital for concerning about their height were short stature^1,2,3).

Nowadays in Korea, many parents and children want to have tall stature and psychosocial stress associated with short stature is increased. Especially, major cause of visit was parents' concerning about their children's height²⁾. Until now, although such psychosocial influences of short stature have been reported, there have been inconsistent reports regarding the short stature that could cause adverse psychosocial consequences. Some studies reported that short children have higher rates of behavioral difficulties and lower social competency, compared with children of normal stature^4,5,6). However, more recent studies reported that short children have normal psychosocial adjustment and the social, emotional, behavioral outcomes did not differ from their nonshort peers^7,8,9,10). However, interpretation of those studies was limited by several factors. Some studies included children with growth hormone (GH) deficiency or other syndromes, which made it unclear whether the underlying pathologic condition or short stature is responsible for the difficulties in psychosocial adjustment^10,11,12). There are few studies regarding parents' anxiety and relatively normal short children concerning their height.

Based on previous reports on relevant topics, we hypothesized that relatively short (R-short) children even if who are not short in medically would have more psychosocial problems (hypothesis 1) and the parents of them will have more stress about child's height (hypothesis 2). As auxiliary hypotheses, we expected that there would be correlations between the score of quality of life (QoL) and height (hypothesis 3). Moreover, in R-short children, parents may have more tendency to use complementary therapy.

This study aimed to evaluate psychopathology, stress, and QoL based on the heights of children and their parents in a local community of a city in Korea. The results showed that children who were R-short considered themselves to be physically weaker than those who were of average height or tall; however, they did not show any differences in terms of psychopathology and stress.

Not many psychopathological studies have been conducted on short children in local communities; however, Voss et al.^18,19,20) conducted a prospect cohort study in 1989, and claimed that low-height children did not have any significant psychosocial issues. The follow-up studies reported that low-height children generally had slightly lower intelligence, but such a finding was more related to other social economic variables than the low height itself^18,19,20). In the present study, the R-short group and other groups did not have any significant differences in social economic factors, and we did not examine their intelligence or academic performance.

As illustrated in the first hypothesis of this study, previous studies reported that low-height children were more vulnerable to psychopathological issues such as anxiety, introversion, stigmatization, and juvenilization. However, those studies were conducted on children who were referred to a pediatric clinic or were given GH injections. Therefore, the results were different from present study^{4,6,21,22,23)}. The psychiatric tools used in this study include the K-CBCL, the BEPSI, and the CHQ-PF50.

Out of the indicators for problematic behavior syndrome in K-CBCL, 11 indicators such as withdrawn, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behavior, aggressive behavior, internalizing problems, externalizing problems, and total problems could be evaluated for the age group in the present study. The T scores of the 3 groups on 11 of these indicators were compared, and none of these items demonstrated significant differences. The parents' evaluation showed that obese children tended to have significantly higher scores for multiple items such as social problems, delinquent behavior, aggressive behavior, externalizing problems, total problematic behavior, etc., than did the overweight and normal-weight children. This suggests that issues with appearance and looks are more related to obesity or overweight, than with height. However, since the present study was conducted on children who were slightly short but who were still in the normal height range, the results could be different from what was expected.

We used the modified BEPSI¹⁷⁾ to evaluate the stress level. The K-BEPSI was developed by Yim et al.²⁴⁾. The modified BEPSI has been proven to be valid and reliable. The present study examined children's stress level based on their parents' report. The total K-BEPSI score of the participants fell between 5 and 25, the average score was 8.17, and the SD was 2.68 in this study. The three height groups did not exhibit any significant differences. Based on the K-BEPSI, 23 children who exhibited scores with SD that was 1.5 or higher were classified as the high stress group. The average height of the high stress group was 162.6 cm (SD, 7.9 cm), which was significantly higher than 154.1 cm (SD, 16.2 cm), the average height of the control group. Such a difference was still significant even when age was adjusted with covariates. Additionally, the difference between weight and BMI was not significant, but BMI of the high stress group tended to be lower. Age of high stress group was significantly higher than control. In summary, we could assume that children who were older age tended to struggle with stress more than others did. On the other hand, their BMI was actually lower, which indicated that they could not properly gain weight due to stress. But it is needed more information to analyze cause of stress in older age (Table 1). Further, the main mental health indexes in the high stress group were evaluated with the K-CBCL, and most of these indexes had lower values. Out of 15 indexes for value of QoL, which was evaluated with the CHQ-PF50, scores on 13 indexes were significantly lower. In other words, stress not only affected children's physical functions but also led to failure in performing expected roles. It also lowered their self-efficacy and mental health, and negatively affected family relationships. This indicates that stress lowers the overall QoL (Tables 2, 3).

The CHQ-PF50 scores of the 3 groups based on height showed that most indicators did not have any significant differences, except for the general health perceptions. Parents with low-height children tended to consider their children to have health problems. The studies showed that these parents preferred providing their children with herbal medicine, growth supplements, and milk as help-seeking behaviors instead of providing them with medical treatment. This suggests that it is necessary to provide low-height children and their parents with accurate medical information. In one similar study, Kusalic et al.²²⁾ reported that low-height children were considered physically weaker than their peers, which led their parents to overprotect them. Previous studies on body measures and the alternative remedies in Korea also showed that various types of alternative remedies were tried when children had lower height, weight, and BMI, but the expected height or the adult height was not significantly affected by how often the alternative remedies were used²⁾.

A short stature, as an isolated physical characteristic, has been investigated as a predictor of an individual's psychological adaptation and QoL. However, it is difficult to conclude the same due to a variety of research models and each restriction. Since there is no evidence that children grow taller when alternative remedies are used, it is vital to help parents understand that short children do not necessarily have health issues, and that they do not need any special medical treatments for being short.

For this, it is necessary to develop and evaluate psychological counseling and cognitive-behavioral intervention programs to support the adaptation process of people with short stature. Additionally, it may not be possible to document evidence that GH treatment improves QoL. However, if the expectation for height is high and the consequent mental stress is severe, as an adjunct or alternative treatment to medical (endocrinological) treatment, growth-promoting therapies are necessary²⁵⁾.

As a supplemental study, the parents' preferred adult height of their children was investigated. The standard growth curve published in 2007 demonstrated that the average height of almost fully-grown teenagers between the ages of 18 and 19 years was 173.4 cm for males and 160.7 cm for females¹³⁾. Parents with children who were R-short and who fell in the 25th percentile or lower in the present study wanted their kids to be taller than the average. Further, these parents' preferred height was 178.4 cm for sons and 163.0 cm for daughters. Additionally, the average height for parents was 172 cm for fathers and 159 cm for mothers, and the parents wanted their children to be at least 5 cm taller than the parents' average height. The taller the kids were currently, the taller the parents wanted them to be in the future. Other studies conducted on adolescents in Korea showed that the preferred average height of children according to parents was 178-180 cm for males and 165-168 cm for females, and this demonstrated that parents' expectations for their children's height was consistently high^2,26).

The present study was significant in that first, it was conducted on children and parents in the local community, while most of the previous studies were conducted on children who visited the clinic or patients with health problems. Secondly, it investigated the height recognition and stress level in R-short children instead of small children who are medically defined to be short because most children who visit growth clinics were in the 25th to 50th percentiles. Finally, the present study is different from others because it enhanced the research methods compared to those used in previous studies by using a variety of measurement methods such as the CBCL, BEPSI, and CHQ-PF50.

However, the results of the present study are limited because the number of children in the low-height group was relatively low, and all measurements were based on parents' report. Such limitations must be improved, and large-scale studies must be conducted in the future.

In conclusion, in the present study, children and their parents in local communities did not show any psychopathological or life value differences based on height. However, when children were short, their parents tended to regard short children as having health problems. Also, the parental expectation for their child's attainable height is unrealistically tall, mostly due to lack of correct medical information.