Puberty and Psychopathology

Adolescence: everyone goes through it, and everyone has different thoughts on how enjoyable, awkward, or downright terrifying it is to experience. The onset of puberty, navigating more complex academic and social challenges (i.e. middle school), and beginning to figure out one’s own identity makes for a formative time of life that can be difficult even for the most well-adjusted child. But lurking behind the curtain of these awkward social and emotional experiences is something more sinister with even more long-lasting influences on an individual’s quality of life: the emergence of psychopathology. While there are certainly prepubescent children who experience emotional distress and mental health concerns, adolescence - and particularly the onset of puberty - creates a unique window of vulnerability to various internalizing and externalizing disorders. Here, I will discuss what we know about the effect of puberty on psychopathology and recent findings regarding the influence of pubertal timing in particular on psychopathology.

For most types of psychopathology, the cause of the illness is not well understood. Many factors, from genetics and personality to environment and parenting styles, all seem to have varying degrees of influence on whether a person develops a particular disorder. A common model that many psychologists have used in an attempt to explain the onset of mental illness is the diathesis-stress model. Simply put, this model posits that while some people may have a genetic makeup that predisposes them to particular diagnoses (diathesis), they must also experience some environmental stressor that ultimately triggers the onset of the illness (stress). These stressors could occur at any point in life, but one stressor that everyone shares is the onset of puberty. Moving forward, I will be using the terms “puberty” and “adolescence” somewhat interchangeably, but it is important to note that these actually refer to two slightly different things. Puberty refers to the hormonal changes and adolescence to the social and cognitive changes that occur during this time period (Sisk & Foster, 2004), which is usually thought of as being during the pre-teen and teenage years.

Puberty and adolescence mark the transition from being a child to an adult, and are characterized by many changes both internally (e.g. brain development, hormone production) and externally (e.g. changing school environments, the advent of dating and relationships). With so much changing in an adolescent’s life all at once, it should come as no surprise that puberty is a period of time associated with an increase in the expression of clinical symptomatology (Mendle, 2014). Both internalizing and externalizing disorders become more prevalent during adolescence, and anxieties related to social situations and evaluation begin to overtake more basic, survival-related fears insofar as how much they affect mental health in the average person (Oldehinkel, Verhulst, & Ormel, 2011). In addition, puberty marks the time when we begin to see sex differences in the prevalence of certain disorders, further cementing this transition’s importance in our greater understanding of mental health across the lifespan. For instance, the most notable shift that occurs in depression prevalence during the pubertal transition is actually not the prevalence of the disorder itself (though that does increase), but the difference in prevalence across genders. Before the onset of puberty, depression is roughly equally prevalent in boys and girls, but by the time adulthood has been reached, women are twice as likely as men to meet diagnostic criteria for some form of depression (Mendle, 2014).

While puberty itself is a universal experience, any one person’s experience of the process will likely differ entirely from another person’s experience. In the past, research that purported to include puberty in its discussion of the development of psychopathology basically used age as a proxy for puberty, but we all know that not everyone starts puberty at the same time. So how do we take into account these individual differences? There’s a whole world of literature about the relationship between mental health and different aspects of puberty, but the most common are those concerning pubertal timing (whether a child experiences the onset of puberty earlier than, later than, or on par with their peers) and pubertal status (a child’s current developmental stage). For example, in anxiety literature in particular, studies have shown the importance of these measures on certain symptoms of anxiety, and that they differentially affect boys and girls (Carter, 2015).

The study of puberty’s relationship to the development of psychopathology has become more widespread in the field, with researchers looking at the role of this transitional phase in specific disorders like depression or anxiety, as well as in dimensional categories such as internalizing or externalizing. Recent research has begun to focus on better capturing what about puberty makes adolescents more vulnerable to various forms of psychopathology, rather than looking at just one diagnosis at a time. Notably, a recent study conducted with over 500 youth between the ages of 9 and 17 found early pubertal timing to be a transdiagnostic risk factor (Hamlat et al., 2019). In their study, they characterized psychopathology in three different ways: by formal diagnostic categories (e.g. depression, ADHD), by dimensional characteristics (internalizing and externalizing), and using a bifactor model (in which one factor p represents an individual’s psychopathology, and internalizing and externalizing are included as secondary factors). Hamlat and colleagues (2019) found that while the first two models demonstrated adequate fit and revealed an effect of both early and late pubertal timing that fit with previous literature (e.g. early timing correlated with conduct disorder and late timing with separation anxiety), the best-fitting model for both boys and girls was the one demonstrating the relationship between early pubertal timing and the p factor.

The results of the study by Hamlat and colleagues (2019) highlights possibilities for the future direction of research on the relationship between puberty and psychopathology. Because they found that early pubertal timing was a risk factor whether looking at specific diagnoses, categories of diagnoses, or psychopathology as a single factor, they have demonstrated the importance of continuing to incorporate measures of puberty and its relative timing into research on psychopathology in adolescents, and provided evidence for the far-reaching and varied effects that puberty can have on psychopathology; that is, some disorders are more affected by early puberty and others by late puberty, but no aspect of psychopathology is entirely unaffected.

Puberty and adolescence represent a time that many of us would like to forget, but when it comes to understanding the development of pretty much any kind of psychopathology, this life stage is a hugely important factor to consider. As scientists and clinicians alike work to understand the human mind, many answers for what makes us human and what makes us vulnerable may very well come from understanding some of the most awkward years of our lives.

References:

Carter, R. (2015). Anxiety Symptoms in African American Youth: The Role of Puberty and Biological Sex. The Journal of Early Adolescence, 35(3), 281-307. https://doi.org/10.1177/0272431614530809.

Hamlat, E. J., Snyder, H. R., Young, J. F., & Hankin, B. L. (2019). Pubertal Timing as a Transdiagnostic Risk for Psychopathology in Youth. Clinical Psychological Science, 7(3), 411–429. https://doi.org/10.1177/2167702618810518.

Mendle, J. (2014). Why Puberty Matters for Psychopathology. Child Development Perspectives, 8(4), 218-222. doi:10.1111/cdep.12092.

Oldehinkel, A.J., Verhulst, F.C., & Ormel, J. (2011). Mental health problems during puberty: Tanner stage-related differences in specific symptoms. The TRAILS study. Journal of Adolescence, 34(1), 73-85. https://doi.org/10.1016/j.adolescence.2010.01.010.

Sisk, C.L. & Foster, D.L. (2004). The neural basis of puberty and adolescence. Nature Neuroscience, 7(10), 1040-1047. doi:10.1038/nn1326.