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Pubertal Stage and Deliberate Self-Harm

in Adolescents
GEORGE C. PATTON, M.D., SHERYL A. HEMPHILL, PH.D., JENNIFER M. BEYERS, PH.D.,
LYNDAL BOND, PH.D., JOHN W. TOUMBOUROU, PH.D., BARBARA J. McMORRIS, PH.D.,
AND RICHARD F. CATALANO, PH.D.

ABSTRACT
Objective: To ascertain the association between pubertal stage and deliberate self-harm. Method: Cross-sectional
survey of 12- to 15-year-olds in 300 secondary schools in the U.S. state of Washington in FebruaryYApril 2002 and the
Australian state of Victoria in JuneYAugust 2002. A total of 3,332 students in grades 7 and 9 provided complete data on
episodes of deliberate self-harm in the previous 12 months and pubertal stage. Pubertal stage was assessed with the
Pubertal Development Scale. Results: The prevalence of deliberate self-harm was 3.7% with a more than twofold higher
rate in females. Late puberty was associated with a more than fourfold higher rate of self-harm (odds ratio 4.6, 95%
confidence interval 1.5Y14) after adjustment for age and school grade level. In contrast age had a protective association
(odds ratio 0.7, confidence interval 0.4Y1.0). The sharpest rises in prevalence across puberty were for self-laceration and
self-poisoning in females. Higher rates of depressive symptoms, frequent alcohol use, and initiation of sexual activity
largely accounted for the association between self-harm and pubertal stage in multivariate models. Conclusions: Puberty
is associated with changes in the form and frequency of self-harm. For adolescents with a gap between puberty and brain
development, risk factors such as early sexual activity and substance abuse may be particularly potent. J. Am. Acad. Child
Adolesc. Psychiatry, 2007;46(4):508Y514. Key Words: puberty, deliberate self-harm, suicidal behavior, parasuicide,
depression, adolescence.

Deliberate self-harm is a major risk factor for suicide adolescents report having engaged in deliberate self-
and one that becomes common in adolescence (Hawton harm at some point in their lives (Hawton and James,
et al., 1997; Velez and Cohen, 1988). Rates of self- 2005). An increasing prevalence in early adolescence
harm rise in the early teen years, particularly in females, parallels higher rates of other health and behavioral
to peak at around 15 years of age (Garrison et al., 1993; problems in the early teens including depression and
Schmidtke et al., 1996). Between 7% and 14% of anxiety (Angold et al., 1998; Patton et al., 1996), eating
disorders (Attie and Brooks-Gunn, 1989), risky sexual
activity (Mezzich et al., 1997), aggressive and antisocial
behavior (Jessor and Jessor, 1977, and substance abuse
Accepted November 7, 2006. (Dick et al., 2000; Martin et al., 2002; Patton et al.,
Drs. Patton, Hemphill, Bond, and Toumbourou are with the Centre for 2004; Wichstrom, 2001).
Adolescent Health, Murdoch Children_s Research Institute and Department of
Paediatrics, University of Melbourne; Drs. Beyers, McMorris, and Catalano are Puberty has been linked to many aspects of ado-
with the Seattle Social Development Research Group, School of Social Work, lescent social adjustment. Males reaching puberty later
University of Washington, Seattle. are less assertive and popular and later in engaging in
This research was supported by funding from the National Institutes of Health
grant DA-12140, the Victorian Health Promotion Foundation, and the
sexual activity (Waylen and Wolke, 2004). By contrast,
Australian Alcohol Education and Rehabilitation Fund. early puberty in females has been consistently associated
Correspondence to George Patton, M.D., Centre for Adolescent Health, 2 with emotional and behavioral problems and earlier
Gatehouse Street, Parkville 3052, Australia; e-mail: george.patton@rch.org.au.
sexual activity (Stattin and Magnusson, 2003). Early
0890-8567/07/4604-508Ó2007 by the American Academy of Child and
Adolescent Psychiatry. studies emphasized the links between early and off-time
DOI: 10.1097/chi.0b013e31803065c7 puberty and social acceptance and integration. Resulting

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PUBERTY AND ADOLESCENT SELF-HARM

peer rejection, emotional immaturity, and low self- ment. Each state used a two-stage cluster sampling procedure. In the
first stage, schools at each study year level were selected at random
esteem were commonly viewed as the factors underlying from a stratified sampling frame of all schools in Victoria, Australia
emotional, behavioral, and health problems (Alsaker, (Catholic, independent, and government) and the U.S. state of
1996; Dick et al., 2000). Findings that pubertal stage Washington (public, private, and alternative). At stage two, single
intact classes from each school for the selected year level were chosen
was associated with female depressive symptoms inde- at random; in a few cases, two classes from different year levels were
pendently of age shifted explanations to a view of randomly chosen from the same school. In Victoria, 165 classes in
puberty as a transition point in risk where there was an 152 schools (65% of eligible classes, N = 254) agreed to participate.
interaction between biological and psychosocial influ- In Washington, 155 classes in 153 schools (73% of those ap-
proached, N = 212) participated. In Victoria, 55 classes participated
ences (Angold et al., 1999; Kessler, 2003; Patton et al., at grade 5 (10Y11 years), 54 at grade 7 (12Y13 years), and 56 at
1996). Changes in family and peer relationships as well grade 9 (14Y15 years). In Washington, 54 classes participated at
as sexual roles have been implicated (Petersen et al., grade 5, 51 classes at grade 7, and 50 classes at grade 9. This
provided samples of approximately 1,000 students in each of grades
1991; Simmons et al., 1979) as has the emergence of 5, 7, and 9 in approximately 300 schools in Washington and
greater life stressors (Jessor, 1991; Orbach, 1996). Victoria in 2002. The data presented in this article were from grade
Psychological style in response to such stressors, such 7 (12Y13 years) and 9 (14Y15 years) students in the first wave
because we did not administer questions about self-harm to the
as ruminative and self-blaming coping styles, may also grade 5 students.
shift at puberty (Bebbington, 1996; Nolen-Hoeksema To establish the generalizability of study samples, participating
and Girgus, 1994; Piccinelli and Wilkinson, 2000). and nonparticipating schools were compared on three school-level
Such changes may be linked to the emergence of a indicators: school type, economic disadvantage, and student
diversity. In Washington, there were no significant differences in
heightened affiliative need in girls compared with boys at school type (public versus private) participating (90.8% public) and
puberty. This may in turn interact with preexisting nonparticipating (93.8%) schools. Rates of participating in a free or
genetic, social, and psychological vulnerabilities to give reduced school lunch program (32.8% versus 31.2%) were similar
rise to depressive symptoms (Cyranowski et al., 2000). in each group. Participating schools had slightly higher proportions
of Hispanic (12.2%) and Native American (3.6%) students than
These considerations may also be relevant for under- schools who refused (6.4% and 2.5%). In Victoria, IYDS school
standing the early adolescent increase in self-harm types were almost identical to proportions of government (public,
(Verberne, 2005). Clarification of the extent to which 69.3%), independent (9.0%), and Catholic (21.7%) schools in the
state. Participating schools in Victoria were overrepresented in
pubertal stage is independently associated with self- having a medium proportion of families receiving an educational
harm should be useful in determining the extent to maintenance allowance compared to nonparticipating schools
which biological changes of puberty may be implicated. (57.4% versus 33.8%). In Victoria, participating schools matched
The current report addresses this question using a study overall state levels of student diversity measured by the proportion of
students who come from homes where the primary language is other
of adolescent development in community samples in than English (17.7% versus 16.6%).
the United States and Australia. Specifically, it ad- We required written parental consent for student participation
dresses three questions: and followed standard data collection protocols approved by the
internal review board of the University of Washington and
1. To what extent is pubertal stage associated with Victoria_s Royal Children_s Hospital_s Ethics in Human Research
Committee. Surveys were administered in classrooms during a 45-
self-harm independently of chronological age or to 60-minute period. Students absent from school on the day of the
school grade level? survey were administered questionnaires later under the supervision
2. To what extent do established risk factors for ado- of school personnel or, in a few cases, on the telephone by study
lescent self-harm, substance abuse, depressive symp- staff. Upon completion of the survey, students in Washington
received $10. Students in Victoria received a small pocket calculator
toms, and early sexual activity mediate a pubertal/ after returning their consent forms.
adolescent increase in self-harm (Hawton et al., Surveys took place in the winter terms in the United States
1997)? (FebruaryYApril 2002) and Australia (JuneYAugust) to control for
possible seasonal changes in behavior or social circumstances.
3. To what extent do changes in social context and/or Student participation rates in Washington in grade 7 were 78.4%
psychological style at puberty explain a pubertal/ (n = 961) and 77.2% in grade 9 (n = 981), for an overall participation
adolescent rise in self-harm? rate of 77.8%. Reasons for nonparticipation included nonreturn of
consent forms (12%) and refusal (10%). Participation rates in
Victoria in grade 7 were 75.6% (n = 984), and 75.5% in grade 9
(n = 973), for an overall participation rate of 75.6%. Reasons for
METHOD
nonparticipation included failure to return the consent form (5%)
The International Youth Development Study (IYDS) is a and refusal (18.7%) by parents or students themselves. The majority
binational, longitudinal study of adolescent health and develop- (91%; n = 1,598) of the Australian sample were of European

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PATTON ET AL.

background, 5% (n = 91) were Asian, and the remainder reported depressive symptomatology were defined by a score of Q11, this
African, Hispanic, Pacific Islander, or Indigenous backgrounds. being the cutoff recommended in the earlier validation studies
More than two thirds (67%: n = 1,177) of the U.S. sample were (Angold et al., 1995).
white, 14% were (n = 237) Hispanic, 8% (n = 140) were Asian Substance use was assessed using self-report items derived from
or Pacific Islander, 5% were (n = 90) Native American, and 4% were the Monitoring the Future surveys (Johnston et al., 2002). Alcohol
(n = 68) black. use in the previous 30 days was classified as none, less than weekly,
or at least weekly. Binge drinking was defined on the basis of one
Measures episode of drinking at least five drinks in a row in the previous 2
weeks.
Student survey items were adapted and extended from the
Communities That Care (CTC) Youth Survey, unless otherwise
indicated. The CTC Youth survey has shown good reliability and Social Context and Psychological Style
validity in large samples across grade levels from 6th through 12th Indices of social context included family attachment, family
grades to study social risk factors for self-harm potentially affected by conflict, poor family management, school commitment, and
pubertal development (Arthur et al., 2002; Pollard et al., 1999). bullying victimization. Indices of psychological style included
Specifically, all scales averaged reliabilities greater than 0.60, with sensation seeking, self-blaming coping style, rational coping style
one exception (Arthur et al., 2002; Glaser et al., 2005). Correlations (Bifulco and Brown, 1996; Hanninen and Aro, 1996), emotional
between risk factor scales and adolescent substance use ranged from regulation (Prior et al., 2000), and impulsivity.
0.08 to 0.64, and correlations between protective factors scales and
substance use outcomes ranged from j0.14 to j0.44 (Arthur et al.,
2002). The construct validity of the survey_s scales has been Statistical Analysis
demonstrated and the measures are equally reliable across males and Data analysis was undertaken using the Stata program (Stata
females and racial/ethnic groups (Glaser et al., 2005). Corp., 2001). Models are presented with robust standard errors to
adjust for the effects of clustering. All prevalence estimates and
Deliberate Self-Harm measures of association have used robust Binformation-sandwich[
estimates of SEs with adjustment for clustering within schools.
Students were asked BIn the past year, have you ever deliberately Multivariate models were constructed using logistic regression with
hurt yourself or done anything that you knew might have harmed you Wald tests used to examine second-order interactions. Puberty was
or even killed you?[ Those who marked Byes[ were then asked the categorized as a three-level ordinal variable, age as a continuous
open-ended question, BWhat was it that you did?[ (Patton et al., variable, and both school grade level (grade 9 versus grade 7) and
1997). Two trained research assistants coded the reported self-harm state of residence as dichotomous variables (Washington versus
behaviors as definite, probable, or absent. Probable self-harm was Victoria).
defined where there was insufficient clarity about intent to inflict
injury. Reports of substance use (alcohol or illicit drugs) were not
coded as self-harm unless the student specified that substances were RESULTS
taken purposely to inflict self-injury or if the description of use was
considered to be inherently dangerous. Intercoder agreement on a We excluded forty-four 16-year-olds and one 17-year-
random 20% (n = 80) of the 405 coded responses was indexed by a old because they were beyond the age at which puberty is
Cohen_s . of 0.77 for definite self-harm and 0.81 for definite or
probable. Self-harm was further categorized into the subtypes of self- usually complete, leaving 1,944 participants in grade 7
laceration, self-poisoning, and other self-harm. Deliberate risk-taking, and 1,910 in grade 9 available for analysis, a potential
self-battering, and jumping from a height were the most common analysis sample of 3,854. Valid self-harm data were
behaviors reported in this last category, which also included a few
instances of self-strangulation and attempted drowning.
available for 3,528 of the 3,854 participants and valid
Pubertal status was assessed in both Victoria and Washington puberty data for 3,618. Data on both variables were
with a modified self-report version of the Pubertal Development available on 3,332 (86%) of all participants. This was
Scale (PDS; Carskadon and Acebo, 1993; Peterson et al., 1988). used as the denominator for all further analyses. The
The PDS had an internal consistency coefficient of 0.79 in males
and 0.69 in females. Pubertal stage was categorized on three mean age of the U.S. students was 14.1 (95% CI
levels: early and prepuberty (stages I and II), mid (stage III), and 13.9Y14.3) years and for the Australian students 13.9
late/completed (stages IV and V). The PDS had an internal (95% CI 13.7Y14.1). Overall, age ranged from 11.8 to
consistency coefficient of 0.79 in males and 0.69 in females. The
overall intraclass correlation between the PDS and separately 16 years. Sixteen percent of males were classified as
administered self-report Tanner scales administered to the Aus- early puberty (n = 263), 40% as mid-puberty (n = 659),
tralian sample was 0.54 (95% confidence interval [CI] 0.26Y0.82). and 54% (n = 708) as late puberty. A majority (63%,
The intraclass correlation tended to be lower in males (0.50, 95%
CI 0.14Y0.86) than females (0.67, 95% CI 0.43Y0.90).
n = 1,231) of females were classified as late puberty, 23%
Depressive symptoms were measured using the Short Mood and (n = 383) as mid-puberty, and 5% (n = 88) as early
Feelings Questionnaire (Angold et al., 1995). This 13-item scale puberty. Half (52%: 877/1,709) of the Australian sample
correlates substantially with the Children_s Depression Inventory and 48% (825/1,623) of the U.S. sample were female.
and the Diagnostic Interview Schedule for Children Depression
scale. It assesses depressive symptoms during the previous 30 days Table 1 shows the prevalence of self-harm and de-
and had an overall ! coefficient of .87 in this sample. High levels of pressive symptoms. Rates of definite (odds ratio [OR]

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PUBERTY AND ADOLESCENT SELF-HARM

TABLE 1 Puberty Stage and Subtypes of Self-Harm


Prevalence Estimates for Self-Harm and Depressive Symptoms
in 3,322 12- to 15-Year-Old Secondary School Students in
Table 3 presents prevalence estimates in early/mid
Victoria and Washington versus late puberty for self-harm categorized into self-
Male Female Total poisoning, self-laceration, and other subtypes. Rates of
(n = 1,630) (n = 1,702) (N = 3,332) self-harm were low in both males and females during
Definite self-harm 2.2 5.0 3.7 early and mid-puberty. In contrast, there are higher
(n = 122) (1.5%Y3.0%) (3.9%Y6.1%) (2.9%Y4.4%) rates of self-laceration and self-poisoning in late puber-
Probable self-harm 3.6 6.3 5.0 ty, particularly in females. Rates of other self-harm did
(n = 166) (2.6%Y4.5%) (5.1%Y7.6%) (4.1%Y5.8%) not differ substantially across early/mid and late pu-
High depressive 17 30 24 berty or between males and females.
symptomsa (15%Y19%) (28%Y33%) (22%Y26%)
(n = 796)
We explored possible mediators of the association
between definite self-harm and pubertal stage in a series
a
Scoring above a cutoff point of 10/11 on the Short Mood and of multivariate logistic regression models (Table 4). The
Feelings Questionnaire.
basic model (Table 2, column 1) was initially adjusted
successively for established risk factors (Table 4) of
2.2, 95% CI 1.6Y3.9) and probable self-harm (OR 1.8, depressive symptoms, frequent alcohol consumption,
95% CI 1.3Y2.6) were higher in females. Rates of and early sexual activity. Depressive symptoms (OR 6.1,
depressive symptoms were similarly higher in females 95% CI 4.2Y9.0), at least weekly alcohol use (OR 4.2,
(OR 2.1, 95% CI 1.7Y2.5). The level of high depressive 95% CI 2.8Y6.3), and initiation of sexual intercourse
symptoms in those not completing the self-harm ques- (OR 4.2, 95% CI 2.7Y6.7) all were robustly associated
tions was similar in males (19%) and females (35%) to with self-harm. Adjusting for these factors substantially
those completing the questions. Overall rates of both reduced the association between pubertal stage and self-
definite (OR 4.4% [95% CI 3.3Y5.6] versus OR 2.0% harm, with the greatest reduction occurring with the
[95% CI 2.1Y3.6]) and probable (OR 6.0% [95% CI addition of depressive symptoms to the model.
4.7Y7.4] versus OR 3.9% [95% CI 3.0Y4.8]) self-harm Two additional models were adjusted for social
were higher in the Victorian sample. context (family attachment, family conflict and
Deliberate Self-Harm, Age, School Grade, and
Pubertal Stage TABLE 2
Two multivariate logistic models in Table 2 show the Adjusted Associations (OR) for Self-Harm With Pubertal Stage,
associations between self-harm (definite and probable) Age, and School Grade Level in 3,332a Secondary School Students
and age, school grade level, and pubertal stage. The in the United States and Australia
odds of definite self-harm were more than fourfold Definite Self-Harm Probable Self-Harm
(n = 122), (n = 166),
higher in late puberty compared to early puberty. The OR (95% CI) OR (95% CI)
odds for probable self-harm were more than fivefold
Pubertal stage
higher in late puberty. In contrast, advancing age and
Pre/early (n = 351) 1.0 1.0
living in the United States was associated with a Mid (n = 1,042) 2.1 (0.7Y6.2) 2.2 (0.8Y5.6)
diminished risk of self-harm. We found an interaction Late/completed 4.6 (1.5Y14.0) 5.4 (2.0Y15)
between gender and school year level in both the (n = 1,949)
definite self-harm (F = 4.3, p = .04) and probable self- Ageb 0.7 (0.4Y1.0) 0.6 (0.4Y0.9)
harm models (F = 3.3, p = .07) with a trend toward Grade 9 (vs. grade 7)
Male (n = 814) 0.7 (0.2Y3.7) 0.7 (0.2Y3.7)
higher rates of self-harm in females in grade 9 compared Females (n = 866) 1.8 (0.7Y4.9) 1.7 (0.7Y4.2)
with males. There were no significant interactions WA (n = 1,623) 0.6 (0.4Y0.9) 0.6 (0.4Y0.9)
between pubertal stage and age for mid-puberty (F = 0.2,
Note: WA = Washington (versus Victoria).
p = .68) or late puberty (F = 0.4, p = .53). No interactions a
This is the total number with both complete self-harm and
were found between other variables including pubertal puberty data.
stage and sex (F = 0.8, p = .39) and pubertal stage and b
Age was entered as a continuous variable ranging from 12 to
state (F = 1.3, p = .27). 16 years.

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PATTON ET AL.

TABLE 3 associated with lower risks of self-harm. No interaction


Prevalencea of Definite Deliberate Self-Harm Subtypes was found between age and pubertal stage, consistent
in Early/Mid Versus Late Puberty
with a view that early maturers are at higher risk of
Males (n = 1,626) Females (n = 1,685)
self-harm because they enter puberty at an earlier point
Early/ Late/ Early/ Late/ and do not have the reduction in risk that comes with
Mid Completed Mid Completed
older age.
Puberty Puberty Puberty Puberty
(n = 1,144) (n = 482) (n = 385) (n = 1,300) The prevalence rate of definite self-harm in this study
was 3.7%, which is slightly lower than previous ado-
Self-laceration 0.9 1.7 0.3 3.5
(n = 72) (0.3Y1.4) (0.4Y2.9) (0Y0.8) (2.4Y4.7) lescent surveys (Hawton et al., 2002; Safer, 1997). Most
Self-poisoning 0 0.3 0.1 1.4 earlier surveys have taken place in mid-adolescence, a
(n = 23) (0Y0.8) (0Y1.3) (0.7Y2.1) point of higher prevalence, and may not have used as
Other self-harm 1.0 1.2 1.3 1.5 rigorous a definition as this study (de Wilde and
(n = 43) (0.5Y1.6) (0.3Y2.2) (0.3Y2.2) (0.8Y2.1) Kienhorst, 1995). When extended to include probable
All self-harm 1.7 3.5 1.8 5.9
(n = 122) (1.0Y2.5) (1.7Y5.3) (0.6Y3.1) (4.6Y7.3)
self-harm, the prevalence rate of 5% is closer to previous
reports.
a
Prevalence estimates (%) and 95% CIs within each group.

TABLE 4
Association (OR) Between Definite Deliberate Self-Harm
management, school connection and commitment, and Pubertal Stage Adjusted for Potential Mediatorsa
and experiences of bullying) and psychological style Further Further
(sensation seeking, impulsivity, emotional control, Adjusted for Adjusted for Adjusted for
and coping style), respectively. Both social context Established Social Psychological
and psychological style change across pubertal stage Risk Factorsb Contextc OR Styled OR
may account for the association between self-harm OR (95% CI) (95% CI) (95% CI)
and pubertal stage. The addition (Table 4) of the Pubertal stage
social context variables did not alter the associations Pre/early (n = 351) 1.0 1.0 1.0
with pubertal stage, age, or school grade but did Mid (n = 1,042) 1.5 1.3 1.4
(0.5Y4.4) (0.4Y3.8) (0.5Y4.5)
slightly reduce associations with depressive symptoms, Late/completed 2.4 1.6 2.4
sexual activity, and weekly alcohol use. The inclusion (n = 1,939) (0.8Y7.3) (0.6Y5.5) (0.7Y7.8)
of indices of psychological style (Table 4) similarly Age 0.6 0.6 0.5
did not change the associations between self-harm and (0.3Y0.9) (0.3Y1.0) (0.3Y0.9)
pubertal stage, age, or school grade. Grade 9 (vs. 7)
Males (n = 814) 1.4 1.4 1.1
(0.2Y7.7) (0.2Y7.4) (0.2Y6.8)
DISCUSSION
Females (n = 866) 2.1 2.4 2.3
Deliberate self-harm becomes common in early (0.9Y8.0) (0.7Y7.7) (0.7Y7.5)
Depressive symptoms 4.1 3.0 2.3
adolescence, with increases in self-poisoning and self-
(n = 846) (2.6Y6.3) (1.7Y5.0) (1.4Y3.8)
laceration particularly marked in females (Hawton Sexually active 2.3 1.9 1.5
et al., 2002). In this study, the odds of self-harm were (n = 240) (1.3Y4.2) (1.0Y3.4) (0.9Y2.9)
four- to fivefold higher in late puberty after adjustment Weekly+ alcohol 2.3 2.0 1.6
for age and school grade level. The association with (n = 378) (1.3Y4.0) (1.1Y3.8) (0.9Y3.0)
pubertal stage was evident in boys but appeared more a
All models also adjusted for state.
striking in girls in whom self-laceration and self- b
Established risk factors are the other variables listed (depressive
poisoning constituted the great proportion of self- symptoms, sexually active, weekly+ alcohol) in the model.
c
harm from late puberty. This association between Social context included scales of family attachment, family
conflict, poor family management, school connection, school
pubertal stage and self-harm diminished substantially
commitment, and bullying. Model adjusted for established risk factors.
after adjustment for depressive symptoms, alcohol use, d
Psychological style included scales of sensation seeking,
and sexual activity, all risk factors for deliberate self- impulsivity, emotional control, self-blaming coping style, and rational
harm known to change at puberty. Being older was coping style. Model adjusted for established risk factor.

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PUBERTY AND ADOLESCENT SELF-HARM

Limitations terns of social interaction may influence the rate and


Some study limitations should be noted. This study form of self-harm (Shugrue and Merchenthaler, 2000).
addressed associations between puberty and substance However, the findings suggest that the greater early
use in children ages 12 to 15 years, so inferences cannot adolescent risk of self-harm may have more to do with
be drawn about children entering puberty at a younger the effect of puberty on depressive symptoms, heavy
point. Although the numbers classified at the early pu- substance use, and sexual activity, all major risk factors
bertal stage were lower than those in mid- and late for self-harm. The protective effect of age was a further
puberty, there remained less than 400 in the early pu- striking finding. Taken with the association with
berty category, a sufficient number to allow analysis of pubertal stage, it may explain why self-harm increases
the associations with pubertal stage independently of sharply in prevalence in the early teens, peaks at around
age and school grade. This limitation is relevant to the the age of 15 years and then falls away rapidly. Much
consideration of the power to detect any sex difference recent attention has focused on early adolescent
in the association of self-harm with pubertal stage be- discrepancies between emotions and emotional control.
cause of the smaller number of girls in the early puberty Brain maturation continues well into late adolescence,
category. However, an advantage of this study is that particularly in brain regions linked to regulation of
both school and individual response rates were reason- behavior and emotion. The development of the pre-
ably high. Participating schools appeared similar to the frontal cortex and expansion of corticocortical com-
profile of schools in each state, but it is possible that the munication, for example, have been consistently found
Washington sample was slightly biased toward ethnic in humans and nonhuman primates (Lewis, 1997;
minority status and to socioeconomic disadvantage in Thompson et al., 2000). Such brain changes correlate
the Victoria sample. At an individual level, nonrespon- with the development of self-control and mature judg-
ders may be more likely to report self-harm and may ment and continue for over a decade after the initiation
differ in their pubertal profiles (Pirie et al., 1988). Such of puberty. Age and its protective association in this
factors may affect the precise estimation of the asso- study may reflect this underlying process. For adoles-
ciations, but seem unlikely to account for the strong cents in whom there is a developmental gap between
associations found here. puberty and brain development, risk factors such as
It is possible that the association between pubertal early sexual activity and substance abuse may be par-
stage and deliberate self-harm arises from confounding ticularly potent.
by earlier social adversities. There is some evidence that
Clinical Implications
childhood sexual abuse and other childhood adversities
such as family conflict may be associated with early In the prevention of and early intervention for self-
menarche (Romans et al., 2003; Zabin et al., 2005). harm, the early teens are likely to be an important life
There is nevertheless a possibility that puberty may phase. Depressive symptoms, substance use, and sexual
switch on genetic or other preexisting vulnerabilities to activity emerge again in this study as important risk
suicidal behavior (Verberne, 2005). Puberty has been factors as well as possible explanatory variables for the
implicated in the activation of serotonergic dysfunction pubertal increase in self-harm. Delaying sexual activity
and consequent dysphoric moods and impulsive behav- as well as alcohol and other substance use may merit
ior in the children of alcoholics (Twitchell et al., 2000). attention in trials aiming to delay the onset of ado-
Such a process could explain the observed increase in lescent self-harm. Given the strong protective associa-
self-harm across pubertal stage as well as the changes in tion with age, delaying the onset of self-harm may
depressive symptoms and substance use. The marked ultimately prove effective in preventing it altogether.
changes in the gender patterning of self-harm between
early and late puberty, with self-poisoning and self- Disclosure: The authors have no financial interests to disclose.
laceration becoming common in girls, would also be
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514 J. AM . ACAD. CH ILD ADOLESC. PSYCHIAT RY, 46:4, APRIL 2007

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