Prepubertal Internalizing Symptoms and Timing of Puberty Onset in Girls

Am J Epidemiol. 2021 Feb 1;190(3):431-438. doi: 10.1093/aje/kwaa223.


Stressful environments have been associated with earlier menarche. We hypothesized that anxiety, and possibly other internalizing symptoms, are also associated with earlier puberty in girls. The Lessons in Epidemiology and Genetics of Adult Cancer From Youth (LEGACY) Girls Study (2011-2016) included 1,040 girls aged 6-13 years at recruitment whose growth and development were assessed every 6 months. Prepubertal maternal reports of daughter's internalizing symptoms were available for breast onset (n = 447), pubic hair onset (n = 456), and menarche (n = 681). Using Cox proportional hazard regression, we estimated prospective hazard ratios and 95% confidence intervals for the relationship between 1 standard deviation of the percentiles of prepubertal anxiety, depression, and somatization symptoms and the timing of each pubertal outcome. Multivariable models included age, race/ethnicity, study center, maternal education, body mass index percentile, and family history of breast cancer. Additional models included maternal self-reported anxiety. A 1-standard deviation increase in maternally reported anxiety in girls at baseline was associated with earlier subsequent onset of breast (hazard ratio (HR) = 1.22, 95% confidence interval (CI): 1.09, 1.36) and pubic hair (HR = 1.15, 95% CI: 1.01, 1.30) development, but not menarche (HR = 0.94, 95% CI: 0.83, 1.07). The association of anxiety with earlier breast development persisted after adjustment for maternal anxiety. Increased anxiety in young girls may indicate risk for earlier pubertal onset.

Keywords: breast development; cohort study; girls; internalizing symptoms; puberty.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Age Factors
  • Body Mass Index
  • Breast / growth & development*
  • Child
  • Continental Population Groups
  • Defense Mechanisms*
  • Female
  • Humans
  • Menarche / physiology*
  • Proportional Hazards Models
  • Prospective Studies
  • Puberty
  • Socioeconomic Factors
  • Stress, Psychological / epidemiology*
  • Stress, Psychological / physiopathology*