psychosocial short stature ( pss ) is characterized by growth failure in association with emotional deprivation . hyperphagic short stature ( hss ) is a variant of pss which has short stature in association with appetite and other behavioral problems . these children demonstrate biochemical evidence of growth hormone ( gh ) insufficiency , but they do not respond to gh therapy . a change in social environment brings about catch - up growth and resolution of behavioral abnormalities . a 5-year - old girl , er , was referred to us for short stature . she was accompanied by her father who had adopted her at the age of 3 years . the father said that she preferred to be alone and avoided playing with other kids . her height and weight were 91.6 cm and 10.5 kg , respectively , which were < <3 centile . her peak gh levels on clonidine and insulin - induced hypoglycemia tests were low ( 3.47 ng / ml and 3.24 ng / ml , respectively ) . thus , she was diagnosed to have isolated growth hormone deficiency ( ghd ) and started on gh therapy ( 10 u / week ) . she was followed three monthly . at the end of 6 months of gh therapy , the response in terms of height gain was very dismal ( 1.5 cm gain in 6 months ) [ figure 1 ] . she had craving for food , stole food from lunchboxes of other children in her class , used to hoard food , and get up at night to eat . father said that she could eat a dozen bananas at one go . in spite of this voracious appetite the mother did not want to adopt her in the first place , and hence the child felt neglected and unwanted . ( c ) after 6 months of gh therapy she was labeled as a probable case of hss . repeat gh stimulation test with clonidine done after 14 days of hospital stay ( away from the psychosocial stress ) showed normal peak gh of 12.5 ng / ml . a change of environment was advised , but was not feasible in the current family setting . hence , the father decided to continue only with the psychiatric therapy ( which included counseling of both er and her parents ) . confirmation of the diagnosis of hss would have required the demonstration of catch - up growth after removal of the stressful environment . though this was not possible in her , we think that strong history of appetite disorder and the very poor response to gh therapy proves our diagnosis of hss in this case . pss is a disorder of short stature and/or delayed puberty that is observed in association with emotional deprivation , a pathologic psychosocial environment , or both . it is also known as  psychosocial dwarfism ,   the kaspar hauser syndrome , it is not classified within psychiatric or medical diagnostic systems ( dsm - iv or icd 10 ) because of its rarity . the name kaspar hauser syndrome comes from description of a person named kaspar hauser who was abandoned at the city gate of nuremburg in 1828 , after 17 years of neglect and isolation in a dungeon carrying a written note that suggested he was 16 years of age . though first described by talbot et al . in 1947 , the link was scientifically proven by powell et al.[24 ] they described 13 children with short stature , emotional disturbances , and abnormal home environments . when placed in a convalescent hospital , these children demonstrated remarkable growth acceleration without receiving gh . several characteristic behavioral features , in particular , appetite disturbance , were described as part of psychosocial dwarfism . further clarified the association between appetite disturbances  hyperphagia , stealing food , eating from rubbish bins , and polydipsia  by defining a distinctive subgroup of pss called hss . in this condition , gh insufficiency was associated with characteristic behavioral features , especially hyperphagia and polydipsia , and a normal body mass index ( bmi ) . such children have the capacity of spontaneous recovery and catch - up growth after removal from the stressful environment . from their data , the authors proposed clinical algorithm for the diagnosis of hss based solely on age , anthropometric data , and behavioral criteria [ table 1 ] . diagnostic criteria for hyperphagic short stature a classification of pss into three groups was postulated by blizzard and bulatovic . if classified within this scheme , hss will fall into type ii , or possibly type iia . type iia refers to hyperphagic patients in whom reversible gh insufficiency is characteristic ; there is rapid catch - up growth with a change of environment and minimal response to gh treatment . the physician should routinely ask whether a child with growth failure and gh deficiency eats excessively , gorges and vomits if given unlimited access to food , steals food at home and school , hoards food , has polydipsia or pica , scavenges from trash cans , or searches for food at night .
a 5-year - old adopted girl was referred to us in view of short stature . after ruling out systemic illness , she was evaluated for growth hormone deficiency ( ghd ) by stimulation tests . 
 the peak value was 3.47 ng / ml . she was then started on growth hormone ( gh ) . at the end of 6 months of gh therapy , her height velocity was only 3 cm / year . 
 there was a lack of attachment between the mother and the child . 
 she had history of hyperphagia , stealing , and hoarding food . 
 psychiatry consultation confirmed that the child had appetite disorder , and hence was diagnosed as hyperphagic short stature ( hss ) . 
 the girl and her parents are undergoing psychiatric therapy for the same . psychosocial dwarfism seems to originate from serious disturbances in the mother  child relationship . 
 these children mimic patients with ghd , but have poor response to gh therapy . 
 this case underscores the importance of social environment in the growth of the individual .