See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/51886018

Self-assessment of pubertal Tanner stage by realistic colour images in

representative Chinese obese and non-obese children and adolescents

Article  in  Acta Paediatrica · December 2011

DOI: 10.1111/j.1651-2227.2011.02568.x · Source: PubMed

CITATIONS READS

19 1,047

3 authors, including:

Ying Sun
Anhui Medical University
48 PUBLICATIONS   861 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Pubertal timing View project

Mental health problems during pubertal transition in China View project

All content following this page was uploaded by Ying Sun on 23 July 2018.

The user has requested enhancement of the downloaded file.

 Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Self-assessment of pubertal Tanner stage by realistic colour images in

representative Chinese obese and non-obese children and adolescents
Ying Sun1,2, Fang-Biao Tao(taofangbiao@126.com)1,2, Pu-Yu Su1,2, China Puberty Research Collaboration*
1.Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui Province, China
2.Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, Anhui Province, China

Keywords ABSTRACT
Body mass index, Overweight, Puberty, Sexual
maturation
Aim: This investigation aims to evaluate the validity of self-assessment of pubertal
Tanner stage in representative Chinese children and adolescents.
Correspondence
Fang-Biao Tao, Department of Maternal, Child &
Methods: The study is a nationally representative cross-sectional survey in eight
Adolescent Health, School of Public Health, Anhui research sites in the large project entitled ‘China Puberty Research Collaboration’. Weight,
Medical University, 81th Meishan Road, Hefei, height, self-assessed pubertal Tanner stage and physical examination of pubic hair in each
Anhui Province, China.
Tel: 86-551-5161168 |
gender, breast development in girls and genital development in boys from were analysed.
Fax: 86-551-3869179 | Realistic colour images of pubertal rating were used as self-assessment of pubertal stage.
Email: taofangbiao@126.com Results: A large proportion of subjects aged 7.9–18.9 years old were capable of
identifying their own pubertal Tanner stage accurately or close to the rater’s assessments.
*School of Public Health, Anhui Medical University, He-
fei, Anhui Province, China; Guangzhou School Student Obese group tends to overestimate their pubertal development compared to non-obese
Health-Care Centers, Guangzhou, Guangdong Province, peers, except for genital assessment in boys. The k values for non-obese and obese girls
China; Department of Maternal, Child & Adolescent
Health, School of Public Health, Fudan University, Shang- were 0.619 (p < 0.0001) and 0.527 (p < 0.0001), respectively, while the k values for
hai, China; School of Publich Health, Kunming Medical non-obese and obese boys were 0.503 (p < 0.0001) and 0.352 (p < 0.0001).
University, Kunming, Yunnan Province, China; Depart-
ment of Maternal, Child & Adolescent Health, School of Conclusions: Self-assessment of the pubertal stage by using realistic colour images
Public Health, Chongqing Medical University, Chongqing, could be a better alternative assessment tool for large epidemiological puberty research
China; School of Public Health, Zhengzhou University,
Zhengzhou, Henan Province, China; School of Public compared with Tanner’s original black and white pictures.
Health, Huazhong University of Science and Technology,
Wuhan, Hubei Province, China; Shenyang School Stu-
dent Healthcare Centers, Shenyang, Liaoning Province,
China.

Received
20 September 2011; revised 18 November 2011;
accepted 13 December 2011.

DOI:10.1111/j.1651-2227.2011.02568.x

INTRODUCTION
Accurate assessment of sexual maturity is an important con-
sideration for many paediatric and adolescent investiga-
tions. Despite the criticisms against the clinical assessment
of pubertal stage by this method, its use has been widely
spread in outpatient routine. Some researchers regarded
self-assessment of Tanner stage as a reasonable substitute
for Tanner stage determined by physical examination, for
the purpose of large-scale, epidemiologic research studies
when physical examination may not be feasible (1,2).
Since early 1980s, many previous studies regarding self-
assessment of pubertal stage in normal weight children and
adolescents have shown inconsistent accuracy of self-
assessment comparatively to the objective assessment of
sexual maturation within each area and across the areas.
The percentage agreement between physician assessment
and self-assessment ranged from 49% to 86% for the Tanner
breast stage (2–6), from 58% to 86% for girls’ Tanner pubic
hair stage (2–6) and from 48% to 78% for boys’ Tanner
pubic hair stage (2,4,6). Factors such as the method chosen,
cultural characteristics and notions of self-image (influ-
enced by the presence or not of overweight, nutritional con-
dition that is knowingly associated with problems related to
self-image perception) are certainly accountable for discrep-
ant results in different populations.
Key notes
• No previous studies have examined self-reports of puber-
tal maturation in large sample and wide age range of nor-
mal weight and obese children and adolescents.
• The realistic, coloured images of pubertal development
could be a good alternative assessment for large epidemi-
ological puberty research.
• Obese group tends to overestimate their pubertal devel-
opment compared to non-obese peers, except for genital
assessment in boys.

ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. e163–e166 e163
Self-assessment of pubertal Tanner stage by realistic colour images
Although high body mass index (BMI) seems to be associ-
ated with early pubertal development (7), little is known
about the effects of fatness on self-assessments of Tanner
stage. Only two studies examined the effect of adiposity on
the sexual maturation assessment in adolescents recruited
from communities (2,8).
To the best of our knowledge, no previous studies have
examined self-reports of pubertal maturation in large sample
and wide age range of normal weight and obese children and
adolescents. We, therefore, compared the accuracy of Tanner
stage self-assessments in a representative sample of Chinese
obese and normal weight children and adolescents by using
colour images of pubertal rating according to Tanner stages,
using data from China Puberty Research Collaboration Sur-
vey which were conducted in eight areas across China.
METHODS
Procedure and sample
This research is framed within the larger project entitled
‘China Puberty Research Collaboration’. The multi-centred
collaboration is initiated by School of Public Health, Anhui
Medical University (Hefei) in Sep 2010, cooperated with
other five medical universities and two school healthcare
centres.
Those eight research sites are representative of eastern
(Shenyang, Shanghai), central (Hefei, Wuhan, Zhengzhou),
western (Chongqing, Kunming), southern (Guangzhou) of
China. The minimum sample size required for each collabo-
rating centres 50 girls and 50 boys of Han ethnicity in each
grade (from grade 1 to grade 12) in rural and urban area,
respectively. Because of the cooperation of local Bureau of
Education, Kunming research centre only obtains 490 and
559 girls in urban and rural areas, respectively.
Figure S1 illustrated the selection procedure of subjects
in this study. Written consent from each participant’s guard-
ian and written assent from each participant were obtained
after providing an explanation of the study.
MEASUREMENT
Assessment of sexual maturity status
Before subjects underwent physical examination, they were
given a standardized series of realistic colour images with
explanatory text to assess their own pubertal development
individually. Those images of pubertal rating according to
Tanner stages (Fig. S2) were proposed by Carel JC and Leger
J published in New England Journal of Medicine in 2008 (9).
In girls, breast development is rated from 1 (preadoles-
cent) to 5 (mature), and stage 2 (appearance of the breast
bud) marks the onset of pubertal development. Pubic hair
stages are rated from 1 (preadolescent, no pubic hair) to 5
(adult), and stage 2 marks the onset of pubic hair develop-
ment. In boys, genital development is rated from 1 (preado-
lescent) to 5 (adult); stage 2 marks the onset of pubertal
development and is characterized by an enlargement of the
scrotum and testis and by a change in the texture and a red-
dening of the scrotal skin. Pubic hair stages are rated from 1
e164
Sun et al.
(preadolescent, no pubic hair) to 5 (adult), and stage 2
marks the onset of pubic hair development.
Subjects from grade 4 to grade 12 were asked to read the
brief descriptions of each stage after which they would
check the box over the picture that best represented them
for each component of development in a private room. Stu-
dents were also given an explanation of some terms to
describe secondary sex characteristics if they requested for
this information.
The physician assessment was conducted on the same
day in a room individually and privately, as part of the phys-
ical examination, by two trained examiners, both experi-
enced in Tanner stage evaluation. The two examiners
assessed only same-sex children and adolescents. Visual
inspection and palpation for breast and genital examination
were requested. The examiner was blinded to the subjects’
self-assessments. Substantial training was conducted to
achieve high level of interrater reliability.
Anthropometric measures
Subjects were measured for height and weight by one obser-
ver using standard techniques with the children standing
without shoes and lightly clothed.
BMI classification reference proposed by Working Group
on Obesity in China (WGOC) was used as screening refer-
ence to calculate the prevalence and trends of over-
weight ⁄ obesity in these groups (10). BMI was categorized
into three groups: BMI < 15 percentile (P15), normal weight
group (BMI between P15 and P85), overweight and obese
group (BMI ‡ P85). The latter two groups were included
into data analysis.
Statistical analysis
The data were analysed by using SPSS 10.01, Chicago, IL,
USA. The correlations between actual and self-reported Tan-
ner stage ratings were examined using Kendall rank correla-
tions, and the differences between actual and self-reported
Tanner stage ratings were examined with the 1-sample sign
test. Tanner stage data were analysed separately for girls and
boys. Additional analyses examined whether Tanner stage
was estimated with equal accuracy in obese and non-obese
subjects. An alpha level of p < 0.05 was set a priori.
The validity of self-assessment versus physician assessment
of pubertal Tanner stage was evaluated by per cent agreement
of the two assessments and by kappa coefficient (j). Accuracy
of self-assessment was defined as the proportion of subjects
who gave the same assessment as the physician. The k coeffi-
cient measures the level of agreement between two indepen-
dent sets of responses, in this case the physician versus
subject assessments of the five Tanner stages.
Kappa ‘Benchmarks’ of the strength of agreement are as
follows: k < 0.01 = poor; 0.01–0.20 = slight; 0.21–
0.40 = fair; 0.41–0.60 = moderate; 0.61–0.80 = substantial;
k > 0.8 = almost perfect (11).
Ethical considerations
The study is approved by the ethical committee of Anhui
Medical University. The study is presented as a study on
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. e163–e166
Sun et al.
growth and puberty timing. All participants and their par-
ents gave informed consent.
RESULTS
Characteristic of study population
A total of 9 132 girls and 6 924 boys were included in our
analysis. The age range of the girls and the boys was 8.0–
18.9 and 7.9–18.9, respectively. The BMI ranged from 18.2
to 54.5 kg ⁄ m2 (mean 25.1± 3.7) in obese boys and 17.2–
53.7 kg ⁄ m2 (mean 23.1± 3.4) in obese girls.
The median ages at stage 2 for breast development of Chi-
nese girls were 9.18 (95% CI 8.91 to 9.44) years and at stage 2
for pubic hair growth were 11.65 (95% CI 11.41–11.90) years.
The median ages at stage 2 for genital development of Chinese
boys were 11.24 (95% CI 11.08–11.41) years and at stage 2 for
pubic hair growth were 12.67 (95% CI 12.46–12.88) years.
Comparison of self-assessment by subjects and physician
assessment in girls
Table S1 showed the comparison of the physician and sub-
ject assessment for breast and pubic hair development in
non-obese and obese girls.
Kendall rank correlation coefficient between breast Tan-
ner stage self-reports and actual ratings for non-obese girls
was 0.766 (p < 0.0001) and for obese girls was 0.735
(p < 0.0001; Fig. S3A). The k value for non-obese girls was
0.619 (p < 0.0001) and for obese girls was 0.527
(p < 0.0001), which indicated substantial reproducibility.
Kendall rank correlation coefficient between pubic hair
Tanner stage self-reports and actual ratings for non-obese
girls was 0.781 (p < 0.0001) and for obese girls was 0.794
(p < 0.0001; Fig. S3B). The k value for non-obese girls was
0.593 (p < 0.0001) and for obese girls was 0.573
(p < 0.0001), which indicated moderate reproducibility.
Figure S3A showed that 353 (17.9%) obese girls overesti-
mated their breast Tanner stage, which is significantly
higher than that of non-obese girls (9.3%) (v2 = 116.25,
p < 0.01). However, there were less obese girls than non-
obese girls that underestimated their breast Tanner stage,
with 18.6% vs. 20.1% (v2 = 2.16, p > 0.05).
Figure S3B showed that 358 (18.2%) obese girls overesti-
mated their pubic hair Tanner stage, which is significantly
higher than that of non-obese girls (14.3%) (v2 = 17.58,
p < 0.01). However, there were more non-obese girls than
obese girls that underestimated their pubic hair Tanner
stage, with 17.7% vs. 14.8% (v2 = 8.96, p < 0.01). There
were no significant differences between accurate estimated
breast and pubic hair Tanner stage between two groups.
Comparison of self-assessment by subjects and physician
assessment in boys
Table S2 showed the comparison of the physician and sub-
ject assessment for genital and pubic hair development in
non-obese and obese boys.
Kendall rank correlation coefficient between genital Tan-
ner stages self-reports and actual ratings for non-obese boys
was 0.778 (p < 0.0001) and for obese boys was 0.639
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. e163–e166
Self-assessment of pubertal Tanner stage by realistic colour images
(p < 0.0001; Fig. S3C). Although self-assessed and mea-
sured Tanner stage ratings were highly correlated, the k
value for non-obese boys was 0.503 (p < 0.0001) and for
obese boys was 0.352 (p < 0.0001), which indicated fair to
moderate reproducibility.
Kendall rank correlation coefficient between pubic hair
Tanner stage self-reports and actual ratings for non-obese
boys was 0.829 (p < 0.0001) and for obese boys was 0.738
(p < 0.0001; Fig. S3D). Although self-assessed and mea-
sured Tanner stage ratings were highly correlated, the k
value for non-obese boys was 0.642 (p < 0.0001) and for
obese boys was 0.446 (p < 0.0001), which indicated moder-
ate to substantial reproducibility.
Figure S3C,D showed that obese boys tend to misclassify
their genital and pubic hair Tanner stage compared with
non-obese boys (p value < 0.01, except for underestimate
for pubic hair stage). Non-obese boys accurately estimated
their genital (60.5%) and pubic hair (72.2%) Tanner stage,
which were significantly higher than that of obese boys
(49.6% and 57.1%, respectively) (p < 0.01).
DISCUSSION
This study evaluated the validity of the self-assessment sex-
ual maturation status (SMS) in 9 132 girls and 6 924 boys
who are representative of mainland Chinese children and
adolescents. Our results suggested that most children were
capable of identifying their own SMS accurately or close to
the rater’s assessments by using the realistic, coloured
images of pubertal development, which resulting in a mod-
erate to almost perfect agreement.
Regarding study participants and study methods, there
were a number of differences between the current study and
previous studies. First, the large and representative sample
size allowed us to fully compare the differences in agree-
ment of self-assessment and rater’s assessment in SMS in
both non-obese and obese boys and girls. Most previous
related studies only included <500 children and adolescents
(1,8). For example, Chan et al. (1) studied 172 boys and 182
girls aged 8–18 years. So far, there were few studies exam-
ined the effect of adiposity on the sexual maturation assess-
ment in adolescents. Lee et al. (8) only investigated 77
morbidly overweight children and adolescents in their
study. Thus, low power affected by small sample size of their
study must be considered.
Differences in the age groups or sexual maturation stages
might be an important reason for these inconsistent find-
ings. Several subjects in previous studies were younger than
15 years old and at the early stages of sexual maturation.
Then, the accuracy of the self-assessment of sexual matura-
tion in overweight adolescents older than 15 years and at
later stages of sexual maturation could not be predicted. In
our study, wide age range (7.9–18.9 years old) made it feasi-
ble to analyse both subjects in early Tanner stage and late
Tanner stage.
While self-assessed SMS in most previous studies used
black and white line drawings by Morris and Udry (2,3,12–
14) or Tanner’s standard photographs (15–18), our study
e165
Self-assessment of pubertal Tanner stage by realistic colour images
used coloured images of pubertal rating according to Tan-
ner stages, proposed by Carel JC and Leger J published in
New England Journal of Medicine in 2008 (9). Those com-
puter-generated, hyper-realistic pictures make it clear and
acceptable for children and adolescents to self-assess their
sexual maturation; thus, it has higher percentage agreement
compared with those of studies using the drawings and Tan-
ner’s standard photographs.
Our study adopted the weighted Kendall rank correlation
statistic to analyse the data, which is a more appropriate
method to evaluate the validity of the pubertal self-assess-
ment, as it allows for differences in the importance of dis-
agreements and gives different weighting to different
responses. Kendall rank correlations between raters’ assess-
ment and children’s self-reported pubertal Tanner stage
were found to be from moderate to substantial
(0.5030.642), with genital assessment in obese boys the
lowest (k = 0.352). The results are in consistent with several
previous researches (14,17).
Our results supported previous findings that children of
normal weight can accurately assess their own stage of sexual
maturation using drawings and pictures and that both obese
and non-obese girls assessed pubic hair Tanner stage without
significant bias. For example, Chan NP et al. found a sub-
stantial agreement for breast Tanner stages, moderate agree-
ment for genital Tanner stages and substantial to almost
perfect agreement for pubic hair Tanner stages in both gen-
ders between self-assessments and rater’s assessments.
Similar to other studies (2,3,17), the agreement in obese
group was found to be lower than that in non-obese group.
Obese children and adolescents tended to assess their sexual
maturity less accurately than did normal weight children and
adolescents. The results might be explained by the difficulty
to distinguish lipomastia from true breast tissue in obese girls.
The present study shows that, in the studied population,
the use of realistic colour images yields high associations with
objective assessment. For the purpose of large-scale, epidem-
iologic research studies when physical examination may not
be feasible, more instructions and explanations should be
given to obese children and adolescents, especially boys.
References
1. Chan NP, Sung RY, Kong AP, Goggins WB, So HK, Nelson EA.
Reliability of pubertal self-assessment in Hong Kong Chinese
children. J Paediatr Child Health 2008; 44: 353–8.
2. Bonat S, Pathomvanich A, Keil MF, Field AE, Yanovski JA.
Self-assessment of pubertal stage in overweight children. Pedi-
atrics 2002; 110: 743–7.
3. Wu Y, Schreiber GB, Klementowicz V, Biro F, Wright D. Racial
differences in accuracy of self-assessment of sexual maturation
among young black and white girls. J Adolesc Health 2001; 28:
197–203.
4. Schlossberger NM, Turner RA, Irwin CE. Validity of self-report
of pubertal maturation in early adolescents. J Adolesc Health
1992; 13: 109–13.
5. Hergenroeder AC, Hill RB, Wong WW, Sangi-Haghpeykar H,
Taylor W. Validity of self-assessment of pubertal maturation in
African-American and European American adolescents. J Ado-
lesc Health 1999; 24: 201–5.
e166
View publication stats
Sun et al.
6. Desmangles JC, Lappe JM, Lipaczewski G, Haynatzki G. Accu-
racy of pubertal Tanner staging self-reporting. J Pediatr Endo-
crinol Metab 2006; 19: 213–21.
7. Rosenfield RL, Lipton RB, Drum ML. Thelarche, pubarche,
and menarche attainment in children with normal and elevated
body mass index. Pediatrics 2009; 123: 84–8.
8. Lee K, Valeria B, Kochman CRN, Lenders CM. Self-assessment
of height, weight, and sexual maturation: validity in overweight
children and adolescents. J Adolesc Health 2002; 39: 346–52.
9. Carel JC, Léger J. Clinical practice. Precocious puberty. N Engl
J Med 2008; 358: 2366–77.
10. Ji CY. Working Group on Obesity in China (WGOC). Report on
childhood obesity in China (4) prevalence and trends of over-
weight and obesity in Chinese urban school-age children and
adolescents, 1985–2000. Biomed Environ Sci 2007; 20: 1–10.
11. Landis JR, Koch GG. The measurement of observer agreement
for categorical data. Biometrics 1977; 33: 159–74.
12. Schall JI, Semeao EJ, Stallings VA, Zemel BS. Self-assessment
of sexual maturity status in children with Crohn’s disease. J Pe-
diatr 2002; 141: 223–9.
13. Norris SA, Richter LM. Usefulness and reliability of tanner
pubertal self-rating to urban black adolescents in South Africa.
J Res Adolesc 2005; 15: 609–24.
14. Taylor SJ, Whincup PH, Hindmarsh PC, Lampe F, Odoki K,
Cook DG. Performance of a new pubertal self-assessment ques-
tionnaire: a preliminary study. Paediatr Perinat Epidemiol
2001; 15: 88–94.
15. Raman A, Lustig RH, Fitch M, Fleming SE. Accuracy of self-
assessed Tanner staging against hormonal assessment of sexual
maturation in overweight African-American children. J Pediatr
Endocrinol Metab 2009; 22: 609–22.
16. Neinstein LS. Adolescent self-assessment of sexual maturation:
reassessment and evaluation in a mixed ethnic urban popula-
tion. Clin Pediatr (Phila) 1982; 21: 482–4.
17. Wacharasindhu S, Pri-Ngam P, Kongchonrak T. Self-assess-
ment of sexual maturation in Thai children by Tanner photo-
graph. J Med Assoc Thai 2002; 85: 308–19.
18. Azevedo JC, Brasil LM, Macedo TB, Pedrosa LF, Arrais RF.
Comparison between objective assessment and self-assessment
of sexual maturation in children and adolescents. J Pediatr (Rio
J) 2009; 85: 135–42.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
Figure S1 RStudy Procedure in flow diagram.
Figure S2 Pubertal rating according to Tanner stages.
Figure S3 Comparison of underestimate, correctly estimate
and overestimate in breast (A), girls’ pubic hair (B), genital
(C) and boys’ pubic hair (D) Tanner stage percentage in boys
between normal weight and overweight and obese groups.
Table S1 Tanner stage for breast and pubic hair develop-
ment in girls: Comparison of self-assessment by subjects
and physician assessment.
Table S2 Tanner stage for genital and pubic hair develop-
ment in boys: Comparison of self-assessment by subjects
and physician assessment.
Please note: Wiley-Blackwell is not responsible for the
content or functionality of any supporting materials
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author
for the article.
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. e163–e166