Elsevier

The Lancet

Volume 369, Issue 9567, 31 March–6 April 2007, Pages 1130-1139
The Lancet

Series
Pubertal transitions in health

https://doi.org/10.1016/S0140-6736(07)60366-3Get rights and content

Summary

Puberty is accompanied by physical, psychological, and emotional changes adapted to ensure reproductive and parenting success. Human puberty stands out in the animal world for its association with brain maturation and physical growth. Its effects on health and wellbeing are profound and paradoxical. On the one hand, physical maturation propels an individual into adolescence with peaks in strength, speed, and fitness. Clinicians have viewed puberty as a point of maturing out of childhood-onset conditions. However, puberty's relevance for health has shifted with a modern rise in psychosocial disorders of young people. It marks a transition in risks for depression and other mental disorders, psychosomatic syndromes, substance misuse, and antisocial behaviours. Recent secular trends in these psychosocial disorders coincide with a growing mismatch between biological and social maturation, and the emergence of more dominant youth cultures.

Section snippets

Puberty

Puberty begins with the poorly understood activation of a complex neuroendocrine network, quiescent since neonatal life.2 Sexual maturation (gonadarche) is initiated with the pulsatile nocturnal release of gonadotrophin releasing hormone from a small number of specialised hypothalamic neurones that in turn leads to the pituitary release of follicle-stimulating hormone and lutenising hormone. The resulting gonadal growth and production of gonadal sex steroids bring about the development of

Pubertal timing

The 4–5 year variation in age of onset of puberty among healthy individuals is a physiological peculiarity of man and is observed even where living conditions are similar for all members of a group.8 This variation reflects a strong genetic component, with nutrition, psychological status, and socioeconomic conditions having additional effects.8, 9, 10 Pathological pubertal delay is most commonly associated with chronic illness, stress, and undernutrition. Precocity is more commonly reported in

Puberty and adolescent development

Early adolescent theorists built on Haeckel's view that individual development (ontogeny) recapitulates evolutionary development (phylogeny). Puberty was typically considered as the trigger to a biologically driven phase of inevitable emotional turmoil18 with biology driving psychological and social development.19, 20 It is now clear that broader social processes define adolescence, not least because its form varies so widely across societies and cultures. In pre-industrial societies the

Brain changes

Many brain changes take place during adolescence. Some precede and initiate puberty. Others continue for around a decade beyond. Yet gonadal hormones affect a wide range of neuronal processes: neurogenesis, dendritic growth, synapse formation and elimination, apoptosis, neuropeptide expression, and sensitivity of neurotransmitter receptors.37 Sex differences in brain development during puberty might reflect the different effects of male and female gonadal hormones. Frontal lobes, which are

Chronic physical illness

General paediatric wisdom has maintained that many of the commonest childhood conditions, such as asthma and other atopic conditions, chronic constipation, and primary nocturnal enuresis, remit in early adolescence. Children were thought to outgrow these conditions due to maturation of the autonomic and central nervous systems under the effect of sex steroids during puberty.50, 51 However, data to support these clinical assumptions are scant. Puberty does not predict remission of asthma, and

Attention deficit hyperactivity disorder, antisocial behaviour, and substance misuse

Until two decades ago, a dominant clinical view was that attention deficit hyperactivity disorder (ADHD) remitted during the transition to adolescence. Findings of recent studies of children with ADHD at puberty have challenged this view. Antisocial behaviour, substance misuse, and academic failure become more prominent during adolescence in individuals with ADHD, and psychostimulants remain useful in the treatment of adolescents with childhood-onset ADHD.62, 63, 64 A decrease in the proportion

Depression and anxiety

Differences between the sexes in internalising emotional disorders characterised by depression and anxiety appear in early adolescence.82 Such disorders commonly persist into adulthood, so that the early adolescent rise in female depression largely accounts for the persisting higher rates of depression in women than in men throughout the reproductive years.83 Evidence of increases in overall prevalence in recent decades suggests that sociocultural influences have a role in development of these

Other mental disorders

Incidence of psychotic disorders markedly increases during the post-pubertal years, more evidently in boys than in girls. A possibility that puberty stimulates pathological brain development in individuals with antenatally acquired brain abnormalities underlies neurodevelopmental hypotheses of schizophrenia.102 The later age of onset for schizophrenia in girls might arise from the different effect of male and female gonadal hormones on brain development.103 Consistent with this hypothesis is

Epilepsy

Frequency of seizures in women with intractable epilepsy changes across the menstrual cycle in response to changing concentrations of oestrogen, which lowers seizure thresholds, and progesterone, which has the reverse effect.113 These effects prompted investigation of changes in epilepsy around the time of menarche. Retrospective studies of patients with ongoing epilepsy suggest that seizures commonly worsened at around menarche in girls.114 Some retrospective studies have also shown that rates

Musculoskeletal disorders, pain and somatic symptoms

The pubertal growth spurt, which is unique to H sapiens, might contribute to musculoskeletal morbidities in adolescence. Bone mineral accretion accelerates during puberty under the influence of gonadal steroids, with peak bone mass achieved by the early 20s.117 Delayed puberty and low weight during puberty can impair bone mineral accretion, leading to osteoporosis and increased fracture risk. So-called growing pains are common in younger adolescents.118 Major musculoskeletal problems such as

Obesity, polycystic ovarian syndrome, and cardiovascular risk

Childhood body fat affects the timing of puberty in a sexually dimorphic pattern, with an association between higher body-mass index (BMI) and earlier onset of menses in girls.130 A suggestion that rising childhood obesity has driven a reduction in the age of puberty in the USA131 seems unlikely, since increasing childhood obesity has not brought change in the timing of puberty elsewhere.132, 133 Whereas boys with higher BMI are more likely to have pubertal delay,134 in girls obesity is

Cancer

Early puberty has been linked to cancer in later life through several mechanisms. Longer duration of exposure to gonadal steroids might increase the risk of steroid-dependent cancers such as breast141 and ovarian cancer142 in women, and possibly prostate cancer in men.143 Increased rates of obesity in early developers might heighten oxidative stresses (hyperglycaemia, hyperleptinaemia, increased lipid concentrations in tissue, inadequate antioxidant defenses, increased rates of free radical

Conclusions and implications

Human puberty probably evolved its unique qualities to ensure that an individual possessed the necessary physical, emotional, and social qualities to ensure successful mating and parenting in primitive social groups. Those characteristics included rapid physical development and a readiness to develop attachments outside the immediate family group. The social context of modern industrialised society differs greatly from what prevailed during human evolutionary history. A delay in social role

Search strategy

The aims in this review were to consider the role of puberty and pubertal timing on the course of pre-existing childhood health problems, the initiation of adolescent health problems, and risk for illness later in life. We searched the MEDLINE, PsychLit, and Embase databases (1996 to December, 2005 for each). We used the terms “puberty”, “menarche”, and “age factors” in combination with: “depression”, “mental disorders”, “substance-related disorders”, “child behavior disorders”,

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