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

508 J. AM . ACAD. CH ILD ADOLESC. PSYCHIAT RY, 46:4, APRIL 2007

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peer rejection, emotional immaturity, and low self-
esteem were commonly viewed as the factors underlying
emotional, behavioral, and health problems (Alsaker,
1996; Dick et al., 2000). Findings that pubertal stage
was associated with female depressive symptoms inde-
pendently of age shifted explanations to a view of
puberty as a transition point in risk where there was an
interaction between biological and psychosocial influ-
ences (Angold et al., 1999; Kessler, 2003; Patton et al.,
1996). Changes in family and peer relationships as well
as sexual roles have been implicated (Petersen et al.,
1991; Simmons et al., 1979) as has the emergence of
greater life stressors (Jessor, 1991; Orbach, 1996).
Psychological style in response to such stressors, such
as ruminative and self-blaming coping styles, may also
shift at puberty (Bebbington, 1996; Nolen-Hoeksema
and Girgus, 1994; Piccinelli and Wilkinson, 2000).
Such changes may be linked to the emergence of a
heightened affiliative need in girls compared with boys at
puberty. This may in turn interact with preexisting
genetic, social, and psychological vulnerabilities to give
rise to depressive symptoms (Cyranowski et al., 2000).
These considerations may also be relevant for under-
standing the early adolescent increase in self-harm
(Verberne, 2005). Clarification of the extent to which
pubertal stage is independently associated with self-
harm should be useful in determining the extent to
which biological changes of puberty may be implicated.
The current report addresses this question using a study
of adolescent development in community samples in
the United States and Australia. Specifically, it ad-
dresses three questions:
1. To what extent is pubertal stage associated with
self-harm independently of chronological age or
school grade level?
2. To what extent do established risk factors for ado-
lescent self-harm, substance abuse, depressive symp-
toms, and early sexual activity mediate a pubertal/
adolescent increase in self-harm (Hawton et al.,
1997)?
3. To what extent do changes in social context and/or
psychological style at puberty explain a pubertal/
adolescent rise in self-harm?
METHOD
The International Youth Development Study (IYDS) is a
binational, longitudinal study of adolescent health and develop-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:4, APRIL 2007
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PUBERTY AND ADOLESCENT SELF-HARM
ment. Each state used a two-stage cluster sampling procedure. In the
first stage, schools at each study year level were selected at random
from a stratified sampling frame of all schools in Victoria, Australia
(Catholic, independent, and government) and the U.S. state of
Washington (public, private, and alternative). At stage two, single
intact classes from each school for the selected year level were chosen
at random; in a few cases, two classes from different year levels were
randomly chosen from the same school. In Victoria, 165 classes in
152 schools (65% of eligible classes, N = 254) agreed to participate.
In Washington, 155 classes in 153 schools (73% of those ap-
proached, N = 212) participated. In Victoria, 55 classes participated
at grade 5 (10Y11 years), 54 at grade 7 (12Y13 years), and 56 at
grade 9 (14Y15 years). In Washington, 54 classes participated at
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
5, 7, and 9 in approximately 300 schools in Washington and
Victoria in 2002. The data presented in this article were from grade
7 (12Y13 years) and 9 (14Y15 years) students in the first wave
because we did not administer questions about self-harm to the
grade 5 students.
To establish the generalizability of study samples, participating
and nonparticipating schools were compared on three school-level
indicators: school type, economic disadvantage, and student
diversity. In Washington, there were no significant differences in
school type (public versus private) participating (90.8% public) and
nonparticipating (93.8%) schools. Rates of participating in a free or
reduced school lunch program (32.8% versus 31.2%) were similar
in each group. Participating schools had slightly higher proportions
of Hispanic (12.2%) and Native American (3.6%) students than
schools who refused (6.4% and 2.5%). In Victoria, IYDS school
types were almost identical to proportions of government (public,
69.3%), independent (9.0%), and Catholic (21.7%) schools in the
state. Participating schools in Victoria were overrepresented in
having a medium proportion of families receiving an educational
maintenance allowance compared to nonparticipating schools
(57.4% versus 33.8%). In Victoria, participating schools matched
overall state levels of student diversity measured by the proportion of
students who come from homes where the primary language is other
than English (17.7% versus 16.6%).
We required written parental consent for student participation
and followed standard data collection protocols approved by the
internal review board of the University of Washington and
Victoria_s Royal Children_s Hospital_s Ethics in Human Research
Committee. Surveys were administered in classrooms during a 45-
to 60-minute period. Students absent from school on the day of the
survey were administered questionnaires later under the supervision
of school personnel or, in a few cases, on the telephone by study
staff. Upon completion of the survey, students in Washington
received $10. Students in Victoria received a small pocket calculator
after returning their consent forms.
Surveys took place in the winter terms in the United States
(FebruaryYApril 2002) and Australia (JuneYAugust) to control for
possible seasonal changes in behavior or social circumstances.
Student participation rates in Washington in grade 7 were 78.4%
(n = 961) and 77.2% in grade 9 (n = 981), for an overall participation
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
nonparticipation included failure to return the consent form (5%)
and refusal (18.7%) by parents or students themselves. The majority
(91%; n = 1,598) of the Australian sample were of European
509
PATTON ET AL.
background, 5% (n = 91) were Asian, and the remainder reported
African, Hispanic, Pacific Islander, or Indigenous backgrounds.
More than two thirds (67%: n = 1,177) of the U.S. sample were
white, 14% were (n = 237) Hispanic, 8% (n = 140) were Asian
or Pacific Islander, 5% were (n = 90) Native American, and 4% were
(n = 68) black.
Measures
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
validity in large samples across grade levels from 6th through 12th
grades to study social risk factors for self-harm potentially affected by
pubertal development (Arthur et al., 2002; Pollard et al., 1999).
Specifically, all scales averaged reliabilities greater than 0.60, with
one exception (Arthur et al., 2002; Glaser et al., 2005). Correlations
between risk factor scales and adolescent substance use ranged from
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
demonstrated and the measures are equally reliable across males and
females and racial/ethnic groups (Glaser et al., 2005).
Deliberate Self-Harm
Students were asked BIn the past year, have you ever deliberately
hurt yourself or done anything that you knew might have harmed you
or even killed you?[ Those who marked Byes[ were then asked the
open-ended question, BWhat was it that you did?[ (Patton et al.,
1997). Two trained research assistants coded the reported self-harm
behaviors as definite, probable, or absent. Probable self-harm was
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
taken purposely to inflict self-injury or if the description of use was
considered to be inherently dangerous. Intercoder agreement on a
random 20% (n = 80) of the 405 coded responses was indexed by a
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-
laceration, self-poisoning, and other self-harm. Deliberate risk-taking,
self-battering, and jumping from a height were the most common
behaviors reported in this last category, which also included a few
instances of self-strangulation and attempted drowning.
Pubertal status was assessed in both Victoria and Washington
with a modified self-report version of the Pubertal Development
Scale (PDS; Carskadon and Acebo, 1993; Peterson et al., 1988).
The PDS had an internal consistency coefficient of 0.79 in males
and 0.69 in females. Pubertal stage was categorized on three
levels: early and prepuberty (stages I and II), mid (stage III), and
late/completed (stages IV and V). The PDS had an internal
consistency coefficient of 0.79 in males and 0.69 in females. The
overall intraclass correlation between the PDS and separately
administered self-report Tanner scales administered to the Aus-
tralian sample was 0.54 (95% confidence interval [CI] 0.26Y0.82).
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).
Depressive symptoms were measured using the Short Mood and
Feelings Questionnaire (Angold et al., 1995). This 13-item scale
correlates substantially with the Children_s Depression Inventory
and the Diagnostic Interview Schedule for Children Depression
scale. It assesses depressive symptoms during the previous 30 days
and had an overall ! coefficient of .87 in this sample. High levels of
510
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depressive symptomatology were defined by a score of Q11, this
being the cutoff recommended in the earlier validation studies
(Angold et al., 1995).
Substance use was assessed using self-report items derived from
the Monitoring the Future surveys (Johnston et al., 2002). Alcohol
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
episode of drinking at least five drinks in a row in the previous 2
weeks.
Social Context and Psychological Style
Indices of social context included family attachment, family
conflict, poor family management, school commitment, and
bullying victimization. Indices of psychological style included
sensation seeking, self-blaming coping style, rational coping style
(Bifulco and Brown, 1996; Hanninen and Aro, 1996), emotional
regulation (Prior et al., 2000), and impulsivity.
Statistical Analysis
Data analysis was undertaken using the Stata program (Stata
Corp., 2001). Models are presented with robust standard errors to
adjust for the effects of clustering. All prevalence estimates and
measures of association have used robust Binformation-sandwich[
estimates of SEs with adjustment for clustering within schools.
Multivariate models were constructed using logistic regression with
Wald tests used to examine second-order interactions. Puberty was
categorized as a three-level ordinal variable, age as a continuous
variable, and both school grade level (grade 9 versus grade 7) and
state of residence as dichotomous variables (Washington versus
Victoria).
RESULTS
We excluded forty-four 16-year-olds and one 17-year-
old because they were beyond the age at which puberty is
usually complete, leaving 1,944 participants in grade 7
and 1,910 in grade 9 available for analysis, a potential
analysis sample of 3,854. Valid self-harm data were
available for 3,528 of the 3,854 participants and valid
puberty data for 3,618. Data on both variables were
available on 3,332 (86%) of all participants. This was
used as the denominator for all further analyses. The
mean age of the U.S. students was 14.1 (95% CI
13.9Y14.3) years and for the Australian students 13.9
(95% CI 13.7Y14.1). Overall, age ranged from 11.8 to
16 years. Sixteen percent of males were classified as
early puberty (n = 263), 40% as mid-puberty (n = 659),
and 54% (n = 708) as late puberty. A majority (63%,
n = 1,231) of females were classified as late puberty, 23%
(n = 383) as mid-puberty, and 5% (n = 88) as early
puberty. Half (52%: 877/1,709) of the Australian sample
and 48% (825/1,623) of the U.S. sample were female.
Table 1 shows the prevalence of self-harm and de-
pressive symptoms. Rates of definite (odds ratio [OR]
J. AM . ACAD. CH ILD ADOLESC. PSYCHIAT RY, 46:4, APRIL 2007
 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.

512 J. AM . ACAD. CH ILD ADOLESC. PSYCHIAT RY, 46:4, APRIL 2007

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Limitations
Some study limitations should be noted. This study
addressed associations between puberty and substance
use in children ages 12 to 15 years, so inferences cannot
be drawn about children entering puberty at a younger
point. Although the numbers classified at the early pu-
bertal stage were lower than those in mid- and late
puberty, there remained less than 400 in the early pu-
berty category, a sufficient number to allow analysis of
the associations with pubertal stage independently of
age and school grade. This limitation is relevant to the
consideration of the power to detect any sex difference
in the association of self-harm with pubertal stage be-
cause of the smaller number of girls in the early puberty
category. However, an advantage of this study is that
both school and individual response rates were reason-
ably high. Participating schools appeared similar to the
profile of schools in each state, but it is possible that the
Washington sample was slightly biased toward ethnic
minority status and to socioeconomic disadvantage in
the Victoria sample. At an individual level, nonrespon-
ders may be more likely to report self-harm and may
differ in their pubertal profiles (Pirie et al., 1988). Such
factors may affect the precise estimation of the asso-
ciations, but seem unlikely to account for the strong
associations found here.
It is possible that the association between pubertal
stage and deliberate self-harm arises from confounding
by earlier social adversities. There is some evidence that
childhood sexual abuse and other childhood adversities
such as family conflict may be associated with early
menarche (Romans et al., 2003; Zabin et al., 2005).
There is nevertheless a possibility that puberty may
switch on genetic or other preexisting vulnerabilities to
suicidal behavior (Verberne, 2005). Puberty has been
implicated in the activation of serotonergic dysfunction
and consequent dysphoric moods and impulsive behav-
ior in the children of alcoholics (Twitchell et al., 2000).
Such a process could explain the observed increase in
self-harm across pubertal stage as well as the changes in
depressive symptoms and substance use. The marked
changes in the gender patterning of self-harm between
early and late puberty, with self-poisoning and self-
laceration becoming common in girls, would also be
consistent with a direct pubertal effect. Sex hormones
act on hippocampal and hypothalamic systems, and by
shifting control of affect, cognitive processes and pat-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:4, APRIL 2007
Copyright @ 2007 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
PUBERTY AND ADOLESCENT SELF-HARM
terns of social interaction may influence the rate and
form of self-harm (Shugrue and Merchenthaler, 2000).
However, the findings suggest that the greater early
adolescent risk of self-harm may have more to do with
the effect of puberty on depressive symptoms, heavy
substance use, and sexual activity, all major risk factors
for self-harm. The protective effect of age was a further
striking finding. Taken with the association with
pubertal stage, it may explain why self-harm increases
sharply in prevalence in the early teens, peaks at around
the age of 15 years and then falls away rapidly. Much
recent attention has focused on early adolescent
discrepancies between emotions and emotional control.
Brain maturation continues well into late adolescence,
particularly in brain regions linked to regulation of
behavior and emotion. The development of the pre-
frontal cortex and expansion of corticocortical com-
munication, for example, have been consistently found
in humans and nonhuman primates (Lewis, 1997;
Thompson et al., 2000). Such brain changes correlate
with the development of self-control and mature judg-
ment and continue for over a decade after the initiation
of puberty. Age and its protective association in this
study may reflect this underlying process. For adoles-
cents in whom there is a developmental gap between
puberty and brain development, risk factors such as
early sexual activity and substance abuse may be par-
ticularly potent.
Clinical Implications
In the prevention of and early intervention for self-
harm, the early teens are likely to be an important life
phase. Depressive symptoms, substance use, and sexual
activity emerge again in this study as important risk
factors as well as possible explanatory variables for the
pubertal increase in self-harm. Delaying sexual activity
as well as alcohol and other substance use may merit
attention in trials aiming to delay the onset of ado-
lescent self-harm. Given the strong protective associa-
tion with age, delaying the onset of self-harm may
ultimately prove effective in preventing it altogether.
Disclosure: The authors have no financial interests to disclose.
REFERENCES
Alsaker FD (1996), The impact of puberty. J Child Psychol Psychiatry
37:249Y258
513
PATTON ET AL.
Angold A, Costello EJ, Erkanli A, Worthman CM (1999), Pubertal changes
in hormone levels and depression in girls. Psychol Med 29:1043Y1053
Angold A, Costello EJ, Messer EC, Pickles A, Winder F, Silver D (1995),
Development of a short questionnaire for use in epidemiological studies
of depression in children and adolescents. Int J Methods Psychiatr Res
5:237Y249
Angold A, Costello EJ, Worthman CM (1998), Puberty and depression: the
roles of age, pubertal status, and pubertal timing. Psychol Med 28:51Y61
Arthur MW, Hawkins JA, Pollard RF, Catalano RF, Baglioni AJ (2002),
Measuring risk and protective factors for substance use, delinquency, and
other adolescent problem behaviors: the Communities That Care Youth
Survey. Eval Rev 26:575Y601
Attie I, Brooks-Gunn J (1989), Development of eating disorders in ado-
lescent girls: a longitudinal study. Dev Psychol 25:70Y79
Bebbington PE (1996), The origins of sex differences in depressive disorder:
bridging the gap. Int Rev Psychiatry 8:295Y332
Bifulco A, Brown GW (1996), Cognitive coping response to crises and onset
of depression. Soc Psychiatry Psychiatr Epidemiol 31:163Y172
Carskadon MA, Acebo C (1993), A self-administered rating scale for
pubertal development. J Adolesc Health 14:190Y195
Cyranowski JM, Frank E, Young E, Shear MK (2000), Adolescent onset of
the gender difference in lifetime rates of major depression. Arch Gen
Psychiatry 57:21Y27
de Wilde EJ, Kienhorst CWM (1995), Suicide attempts in adolescence:
Bself-report[ and Bother-report[. Crisis 16:59Y62
Dick DM, Rose RJ, Viken RJ, Kaprio J (2000), Pubertal timing and sub-
stance use: associations between and within families across late ado-
lescence. Dev Psychol 36:180Y189
Garrison CZ, McKeown RE, Valois RF, Vincent ML (1993), Aggression,
substance use and suicidal behaviors in high school students. Am J Public
Health 83:179Y184
Glaser RR, Van Horn ML, Arthur MW, Hawkins JD, Catalano RF (2005),
Measurement properties of the Communities That Care Youth Survey
across demographic groups. J Quant Criminol 21:73Y102
Hanninen V, Aro H (1996), Sex differences in coping and depression among
young adults. Soc Sci Med 43:1453Y1460
Hawton K, Fagg J, Simkin S, Bale E, Bond A (1997), Trends in deliberate
self-harm in Oxford, 1985Y1995. Implications for clinical services and
the prevention of suicide. Br J Psychiatry 171:556Y560
Hawton K, James A (2005), Suicide and deliberate self-harm in young
people. BMJ 330:891Y894
Hawton K, Rodham K, Evans E, Weatherall R (2002), Deliberate self harm
in adolescents: self report survey in schools in England. BMJ 325:
1207Y1211
Jessor R (1991), Risk behavior in adolescence: a psychosocial framework for
understanding and action. J Adolesc Health 12:597Y605
Jessor R, Jessor SL (1977), Problem behavior and psychosocial development: a
longitudinal study of youth. San Diego: Academic Press
Johnston LD, O_Malley PM, Bachman JG (2002), Monitoring the future
study: a continuing study of the lifestyles and values of youth. Ann Arbor:
University of Michigan/National Institute on Drug Abuse
Kessler RC (2003), Epidemiology of women and depression. J Affect Disord
74:5Y13
Lewis DA (1997), Development of the prefrontal cortex during adolescence:
Insights into vulnerable neural circuits in schizophrenia. Neuropsycho-
pharmacology 16:385Y398
Martin CA, Kelly TH, Raynens MK et al. (2002), Sensation seeking, puberty,
and nicotine, alcohol, and marijuana use in adolescence. J Am Acad Child
Adolesc Psychiatry 41:1495Y1502
Mezzich AC, Tarter RE, Giancola PR, Lu S, Kirisci L, Parks S (1997),
Substance use and risky sexual behavior in female adolescents. Drug
Alcohol Depend 44:157Y166
Nolen-Hoeksema S, Girgus JS (1994), The emergence of gender differences
in depression during adolescence. Psychol Bull 115:424Y443
514
Copyright @ 2007 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
Orbach I (1996), The role of body experience in suicidal behavior. Clin
Child Psychol Psychiatry 1:607Y619
Patton GC, Harris R, Carlin JB et al. (1997), Adolescent suicidal behaviors:
a population-based study of risk. Psychol Med 27:715Y724
Patton GC, Hibbert ME, Carlin J et al. (1996), Menarche and the onset of
depression and anxiety in Victoria, Australia. J Epidemiol Commun
Health 50:661Y666
Patton GC, McMorris BJ, Toumbourou JW, Hemphill SA, Donath SM,
Catalano RF (2004), Puberty and the onset of substance use and abuse.
Pediatrics 114:e300Ye306
Petersen AC, Sarigiani PA, Kennedy RE (1991), Adolescent depression: why
more girls? J Youth Adolesc 20:247Y271
Peterson AC, Crockett L, Richards M, Boxer A (1988), A self-report
measure of pubertal status: reliability, validity and initial norms. J Youth
Adolesc 17:117Y133
Piccinelli M, Wilkinson G (2000), Gender differences in depression: critical
review. Br J Psychiatry 177:486Y492
Pirie PL, Murray DM, Lupter RV (1988), Smoking prevalence in a cohort of
adolescents including absentees, dropouts and transfers. Am J Public
Health 78:176Y178
Pollard RF, Hawkins JD, Arthur MW (1999), Rick and protection; are both
necessary to understand diverse behavioural outcomes? Soc Work Res 23:
145Y158
Prior M, Sanson A, Smart D, Oberklaid F (2000), Pathways from Infancy to
Adolescence: Australian Temperament Project 1983Y2000. Melbourne:
Australian Institute of Family Studies
Romans SE, Martin JM, Gendall K, Herbison GP (2003), Age of menarche:
the role of some psychosocial factors. Psychol Med 33:933Y939
Safer DJ (1997), Self-reported suicide attempts by adolescents. Ann Clin
Psychiatry 9:263Y269
Schmidtke A, Bille-Brahe U, DeLeo D et al. (1996), Attempted suicide in
Europe: rates, trends and sociodemographic characteristics of suicide
attempters during the period 1989Y1992. Results of the WHO/EURO
Multicentre Study on Parasuicide. Acta Psychiatr Scand 93:327Y338
Shugrue PJ, Merchenthaler I (2000), Estrogen is more than just a Bsex
hormone[: novel sites for estrogen action in the hippocampus. Front
Neuroendocrinol 21:95Y101
Simmons RG, Blyth DA, VanCleave EF, Bush DM (1979), Entry into early
adolescence: the impact of school structure, puberty and early dating on
self-esteem. Am Sociol Rev 44:948Y967
Stata Corporation (2001), STATA Release 7.0. College Station, TX: Stata
Corporation
Stattin H, Magnusson D (2003), Pubertal Maturation in Female Develop-
ment. Hillsdale, NJ: Lawrence Erlbaum Associates
Thompson PM, Giedd JN, Woods RP, MacDonald D, Evans AC, Toga
AW (2000), Growth patterns in the developing brain detected by using
continuum mechanical tensor maps. Nature 404:190Y193
Twitchell GR, Hanna GL, Cook EH, Fitzgerald HE, Zucker RA (2000),
Serotonergic function, behavioral disinhibition, and negative affect in
children of alcoholics: the moderating effects of puberty. Alcohol Clin
Exp Res 24:972Y979
Velez CN, Cohen P (1988), Suicidal behavior and ideation in a community
sample of children: maternal and youth reports. J Am Acad Child Adolesc
Psychiatry 27:349Y356
Verberne TJ (2005), A developmental model of vulnerability to suicide:
consistency with some recurrent findings. Psychol Rep 89:217Y226
Waylen A, Wolke D (2004), Sex Fn_ drugs Fn_ rock Fn_ roll: the meaning and
social consequences of pubertal timing. Eur J Endocrinol 151:
U151YU159
Wichstrom L (2001), The impact of pubertal timing on adolescents: alcohol
use. J Res Adolesc 11:131Y150
Zabin LS, Emerson MR, Rowland DL (2005), Childhood sexual abuse and
early menarche: the direction of their relationship and its implications.
J Adolesc Health 36:393Y400
J. AM . ACAD. CH ILD ADOLESC. PSYCHIAT RY, 46:4, APRIL 2007