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The Kaspar Hauser Syndrome of 'Psychosocial Dwarfism': Deficient Statural, Intellectual, and Social Growth Induced by Child Abuse.

For many years, endocrinologists and psychiatrists have been fascinated by children with 'psychosocial dwarfism' whose growth in stature is impaired, often to a dramatic degree, consequent to serious abuse or neglect. John Money has contributed several important papers to the scientific literature on the subject, and his experience of diagnosing and treating children with this condition must be as great as that of anyone in the world. He is professor of medical psychology and professor of paediatrics emeritus at the Johns Hopkins University Hospital and the founder of the Psychohormonal Research Unit.

In this book, he competently reviews the existing literature, setting it within the context of an historical account of Kaspar Hauser, whose story introduces and concludes the discussion of clinical material about psychosocial dwarfism. Kaspar Hauser was found at the Haller Gate of the city of Nuremberg in 1828, carrying a written note that suggested he was 16 years of age. Even for a child of those times he was stunted in growth, and he had little coherent speech. Eventually, a story was pieced together suggesting that he had been brought up in a small dark room, fed by an unknown hand, and throughout his life he had experienced almost total isolation from human contact. Although never proven, it has been suggested that he was the son of nobility and that for political reasons his existence had to be denied. Just five years after his discovery, Kaspar was murdered by a stranger in a public park to which he had been lured on the pretext that he would learn something of his true heritage.

Children with psychosocial dwarfism are rare. In the world literature on the subject, no more than one hundred cases have ever been described. The key features include, first, a very slow rate of linear growth with height for age among the lowest 1 per cent of the population. Second, there are remarkable features of behaviour, including a disrupted sleep pattern (with wandering at night in search of food a usual symptom), hyperphagia (an insatiable appetite), polydipsia (an insatiable thirst) and pain agnosia (an insensibility to physical discomfort). Social relationships with both peers and adults are characterized by their poverty of affect. The children are usually miserable and hyperactive and have a low self-esteem. An important feature, one on which Money himself has written, is cognitive impairment: the appearance is often of a child with moderate to severe learning difficulties.

The condition has proved of such interest to endocrinologists and psychologists because it is the most remarkable example of a psychoneuroendocrinological disorder that we know. When they present, often to a growth clinic, affected children appear to be suffering from hypopituitarism (that is to say, they appear not to be producing growth hormone from their pituitary gland). Isolated growth hormone deficiency is rare and needs treating with exogenous growth hormone. However, if this treatment is given to children with psychosocial dwarfism, it does not work: they do not grow any faster. Yet, once it is recognized that they are being abused and they are removed from their abusive environment, their height increases at a greatly accelerated rate with no treatment at all! As Money has shown, the associated intellectual retardation usually improves as well, alongside the growth, and the catch-up can be as great as 50 IQ points or more.

Money does a competent job of reviewing a well-known literature on the effects of an institutional rearing upon development and on the consequences of an upbringing in conditions of extreme isolation. (A few case histories are known of children whose long-term imprisonment in cellars and attics has been far better documented than that of Kaspar Hauser, but what those cases have to do with psychosocial dwarfism is a debatable point.) Recent research has suggested that growth failure in conditions of psychosocial adversity is a spectrum of disorders of which psychosocial dwarfism, as described here, is just one extreme. There is good evidence now to suggest that children with the classical symptoms may be genetically vulnerable to respond to abuse in a characteristic way.

I do wonder whether he is correct in concluding that the key diagnostic features of hyperphagia and polydipsia are likely to be a consequence of food and fluid restriction by parents. Without going into a long discussion here, it is worth reflecting that those symptoms are usually prominent features of behaviour at school as well as at home. Also, when the children are 'rescued', into either a hospital or a foster home, there is usually a rapid resolution of the behaviours and little evidence of an excessive appetite thereafter. The children do not act as though they have been starved, and their weight gain is far less impressive than the recovery in their linear growth.

A not insubstantial proportion of this book is devoted to a discussion of 'The paleodigms of sacrifice' and 'Lovemaps'. Try as I might, I found it difficult to reconcile the contents of these chapters, which concern the idiosyncrasies of sexual behaviour, a topic on which Money has written widely in recent years, with the main subject matter. The statement, 'sexual not a prominent feature of sacrificial abuse in the syndrome of abuse dwarfism', is in my experience an inaccurate observation which may reflect a general lack of awareness of the prevalence of that problem among abused children.

For those who are unfamiliar with the literature on extreme deprivation of human contact upon physical and mental development, The Kaspar Hauser Syndrome could serve as a useful introduction. Combining historical and clinical insights, it certainly takes a broad view of its subject. Whether psychoneuroendocrinology will be, as Money seems to believe, the future of brain science in the 21st century, remains to be seen.

DAVID SKUSE (Institute of Child Health, University of London)
COPYRIGHT 1995 British Psychological Society
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Copyright 1995 Gale, Cengage Learning. All rights reserved.

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Author:Skuse, David
Publication:British Journal of Psychology
Article Type:Book Review
Date:Nov 1, 1995
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