Validity of Self-Assessment of PubertalMaturationAnna R. Rasmussen, MD, Christine Wohlfahrt-Veje, MD, PhD, Katrine Tefre de Renzy-Martin, MD, Casper P. Hagen, MD, PhD,Jeanette Tinggaard, MD, Annette Mouritsen, MD, PhD, Mikkel G. Mieritz, MD, Katharina M. Main, MD, PhD

abstract BACKGROUND AND OBJECTIVES: Studies of adolescents often use self-assessment of pubertalmaturation, the reliability of which has shown conflicting results. We aimed to examine thereliability of child and parent assessments of healthy boys and girls.

METHODS: A total of 898 children (418 girls, 480 boys, age 7.4–14.9 years) and 1173 parents(550 daughters, 623 sons, age 5.6–14.7 years) assessed onset of puberty or development ofbreasts, genitals, and pubic hair according to Tanner stages by use of a questionnaire anddrawings. Physicians’ assessments were blinded and set as the gold standard. Percentageagreement, k, and Kendall’s correlation were used to analyze the agreement rates.

RESULTS:Breast stage was assessed correctly by 44.9% of the girls (k = 0.28, r = 0.74, P, .001) andgenital stage by 54.7% of the boys (k = 0.33, r = 0.61, P , .001). For pubic hair stage 66.8% ofgirls (k = 0.55, r = 0.80, P , .001) and 66.1% of boys (k = 0.46, r = 0.70, P , .001) made correctassessments. Of the parents, 86.2% correctly assessed onset of puberty in girls (k = 0.70, r = 0.71,P , .001) and 68.4% in boys (k = 0.30, r = 0.37, P , .001). Children who underestimated wereyounger and children who overestimated older than their peers who made correct assessments.Girls and their parents tended to underestimate, whereas boys overestimated their pubertal stage.

CONCLUSIONS: Pubertal assessment by the child or the parents is not a reliable measure of exactpubertal staging and should be augmented by a physical examination. However, for largeepidemiologic studies self-assessment can be sufficiently accurate for a simple distinctionbetween prepuberty and puberty.

WHAT’S KNOWN ON THIS SUBJECT: Manypopulation-based studies including pubertalchildren are based on self-assessment ofpubertal maturation, the reliability of which isuncertain.

WHAT THIS STUDY ADDS: Self-assessment is notreliable for precise pubertal staging. Simpledistinctions between prepuberty and pubertyshowed moderate agreement with clinicalexaminations. Parents and girls tended tounderestimate and boys to overestimatepubertal development by up to 50% and 30%,respectively.

University Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen,Denmark

Dr Rasmussen performed clinical examinations of children and was the main person responsiblefor data analysis and writing of the manuscript; Dr Wohlfahrt-Veje conceptualized, designed, andsupervised the data collection and analysis, performed clinical examinations of the participants,participated in the drafting of the manuscript, and critically reviewed the final manuscript;Drs Hagen, Mouritsen, Tefre de Renzy-Martin, Tinggaard, and Mieritz participated in the pubertystudy design and performance of clinical examinations and revised the final manuscript; ProfessorMain conceptualized, designed, and supervised the data collection and analysis and criticallyrevised the final manuscript; and all authors approved the final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-0793

DOI: 10.1542/peds.2014-0793

Accepted for publication Sep 29, 2014

Address correspondence to Anna R. Rasmussen, MD, Department of Growth and Reproduction,Section 5064, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. E-mail: anna.roe.rasmussen@sund.ku.dk

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

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Pubertal development includesa multitude of physiologic andpsychological changes, which stronglyaffect observations linked to outcomeparameters such as biology, behavior,and intellectual performance. Thus,a study of older children andadolescents requires having a validassessment of pubertal onset andpreferably also maturation stages.

Pubertal development is traditionallyclassified into 5 stages for breast(B1–B5) and genital (G1–G5)development and pubic hair growth(PH1–PH5).1,2 In addition, testicularvolume is usually measured, anda volume .3 mL by orchidometry isgenerally accepted as a marker ofpubertal onset with testicularsecretion of testosterone.3 Pubic hairusually follows testicular growthand breast development in boys andgirls, respectively.4 The age atpubertal onset varies betweengenders and individuals and is knownto be influenced by many factors suchas ethnicity, nutrition, genetics, andenvironment.5–8

For clinical or epidemiologic studiesin which exact pubertal stages arerequired, many aspects must be takeninto consideration. Some childrenmay feel uncomfortable with thephysical examination, and individualassessments are time consuming,logistically challenging, and expensivein large populations. In somecultures, physical examinations ofhealthy children may not be ethicallyacceptable. Many studies thereforerely on self-assessmentquestionnaires with pictures orquestions or on the use of a pubertaldevelopment scale, where childrenare asked to rank theirdevelopment.9–12

Previous investigations of thereliability of self-assessment haveshown conflicting results. Somestudies found reasonable agreementbetween self-assessment andexamination by a physician,13–16

whereas others founddiscrepancies.17–20 Most studies

include few children (girls, n = 37–182; boys, n = 23–172) in view of thebroad age range of puberty. Wetherefore aimed to validate self-assessment of sexual maturationcompared with clinical examinationby trained physicians in a largecohort of boys and girls.

Other studies have compared self-assessment with parental assessmentor have used parental assessment asthe only evaluation method.21,22 Toour knowledge only 1 previous studyof girls and mothers has comparedparental assessment with physician’sexamination.23 This study foundreasonable correlation rates. Wetherefore aimed to examine thereliability of parental assessmentalso.

METHODS

Study Population

This study was based on data from anongoing population-based mother–child cohort conducted inCopenhagen, Denmark. Mothers wererecruited between 1997 and 2003 inearly pregnancy from 3 universityhospitals. Only white mothers ofDanish origin were included in thecohort. The cohort has previouslybeen described in detail.24–26

Between 2010 and 2012 all 2647children were invited fora longitudinal puberty follow-up, and1284 (48.5%) agreed to participate(Fig 1). Children who did notparticipate in the follow-up study(n = 1363) did not differ significantlyfrom the included children in gender,socioeconomic status, birth weight(weight for gestational age), or BMI(SD scores for age and gender) at anytime during the examinations beforethe pubertal follow-up (all Ps $.2).

At the first examination, at medianage 10.9 years for daughters (range6.2–14.7) and 10.6 years for sons(5.6–14.2), parents (biological motheror father) were requested byquestionnaire to assess pubertaldevelopment of their child before

clinical examination (Table 1). A totalof 111 children were excluded; 56 didnot feel comfortable having a physicalexamination, and 23 never returnedthe questionnaire or returned thequestionnaire$90 days before (n = 19)or after (n = 13) the examination date.

At the second examination, medianage 11.8 years for daughters (range7.4–14.9) and 11.4 years for sons(7.9–14.9), children were requestedto self-assess pubertal development(Table 1). All 1284 children wereinvited, and 79.8% (n = 1025) agreedto participate. A total of 127 childrenwere excluded; 60 did not feelcomfortable having a physicalexamination, 46 never returned thequestionnaire, 7 answered incorrectly,2 did not want to answer thequestionnaire, and the rest answered$90 days before (n = 7) or after (n = 5)the examination date.

The study was conducted accordingto the Helsinki II Declaration andapproved by the local ethicscommittee (KF 01-030/97. KF01276357, H-1-2009-074) and theDanish Data Protection Agency(1997-1200-074, 2005-41-5545,2010-41-4757). The parents andchildren gave their written informedconsent before examination.

Clinical Examination

Pubertal stages were assessedaccording to Tanner and Marshall1,2

by 6 trained physicians, and theirratings were set as the gold standard.The physicians were blinded to bothparental and adolescentquestionnaires. Palpation was used todifferentiate between fat and breasttissue. If breast stage differedbetween left and right side, thehighest stage was used for analysis.

The examiners in the studyparticipated in repetitive workshops toensure and maintain standardization.In a pilot study (n = 26), evaluation ofbreast stages (right side) was doneindependently by 2 examiners, andagreement for onset of breastdevelopment was 100%. The

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interobserver agreement was 84.6%(n = 22), k was 0.78 (P , .001), andthe correlation (Kendall’s coefficient)was 0.87, P , .001.

Height was measured by using a wall-mounted stadiometer to the nearestmillimeter (Holtain Ltd, Crymych,United Kingdom) and weight wasmeasured to the nearest 0.1 kg usingelectronic scales (SECA d model 707,Hamburg, Germany; and Bisco modelPERS 200, Farum, Denmark).

Self-Assessment and Questionnaires

Fourteen days before the firstscheduled examination a questionnairewas sent to the parents. They wereasked, “Is your child in puberty YES/NO.”They were also asked what thefirst signs of puberty had been bychoosing between breast and/or pubichair for girls and pubic hair for boys.Parents were not asked about theirson’s genital stage. The questionnairewas returned before the examination.

Fourteen days before the secondexamination, a self-assessmentquestionnaire with illustrations of the5 pubertal stages (Fig 2) including anexplanatory text was sent to thefamilies. The children were asked tomark the appropriate developmentstage by themselves or together witha parent. The questionnaires werereturned before the clinicalexamination. If the families did notcomplete the questionnaire before theexamination, they were asked toreturn it by mail later (firstexamination n = 32, secondexamination n = 17).

Statistics

All statistical analyses were carriedout using SPSS software (version20.0; IBM SPSS Statistics, IBMCorporation). Outcomes wereanalyzed either as ordinal data(Tanner stages 1–5) or dichotomized(1 vs 2–5) according to prepubertalor pubertal status.

To examine the agreement betweenchild or parental assessment andclinical examination, we used3 approaches.

Cohen’s k coefficient is a statisticalmeasure of interrater agreement.Strength of agreement: ,0.00, poor;0.00 to 0.20, slight; 0.21 to 0.40, fair;0.41–0.60, moderate; 0.61–0.80,substantial; .0.80, almost perfect.27

Kendall’s t-b provides an estimate ofthe similarity of the ordering of data.Perfect agreement corresponds toa coefficient of 1, whereas totaldisagreement (1 ranking is theopposite of the other) corresponds toa coefficient of 21. Zero indicates theabsence of association.

Sensitivity and specificity for parentaland participant assessment incomparison with clinical examinationwere calculated on dichotomizeddata: prepubertal (Tanner 1) versuspubertal (Tanner 2–5). The sensitivityshowed how accurately the childrenand parents assessed the presence ofpuberty or secondary sexcharacteristics (true positive), and the

FIGURE 1Flowchart of inclusion of participants.

TABLE 1 Study Population Characteristics

Median (Range) Median (Range)

First Visit With Parental Assessment

Girls (n = 550) Boys (n = 623)

Age, y 10.9 (6.2–14.7) 10.6 (5.6–14.2)BMI 17.0 (12.4–31.2) 16.7 (13.1–28.1)Wt, kg 36.4 (17.4–78.3) 35.0 (18.0–78.4)Height, cm 146.6 (112.9–177.7) 145.4 (113.2–182.9)

Second Visit With Participant Self-Assessment

Girls (n = 418) Boys (n = 480)

Age, y 11.8 (7.4–14.9) 11.4 (7.9–14.9)BMI 17.6 (13.2–33.8) 17.4 (13.1–31.5)Wt, kg 41.3 (20.5–92.1) 39.4 (23.0–98.6)Height, cm 153.0 (118.4–179.1) 150.9 (124.6–192.4)

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specificity showed how accurate theywere in assessing the absence thisdevelopment (true negative).

Differences between populationcharacteristics of included, excluded,and nonparticipating children weretested by Mann–Whitney U test(continuous variables) andx2 (categorical variables). The firstmentioned test was also used toanalyze was also used to analyzedifferences in BMI and age betweenchildren who underestimated oroverestimated and children whomade correct assessments.

RESULTS

No significant differences were foundfor the girls between participants andexcluded children with regard to age,BMI, height, and weight (P . .1). Inboys, median age (11.2 years, range7.5–13.6; P = .004), weight (38.0 kg,range 23.2–62.8; P = .005), and height(148.6 cm, range 122.2–172.7;P = .004) at first examination weresignificantly higher in excludedchildren. The agreements betweenphysician assessment and self-assessment are shown in Table 2(girls) and Table 3 (boys).

Girls’ Self-Assessment

Self-assessment of girls showed slightto fair agreement with clinicalassessment of breast and pubic hairstage, with a moderate agreement forpubertal onset. Specificity andsensitivity were high for theassessment of puberty and secondarysex characteristics (Table 4). In thegroup of girls, 90.2% (n = 377) wereable to correctly assess whether theywere in puberty. More girlsunderestimated (8.6%, n = 36) thanoverestimated (1.2%, n = 5) theirpubertal development.

FIGURE 2Gender-specific self-assessment questionnaire for children, containing both illustrations and explanatory text, modified from a previous study.14 (Text wastranslated from an original Danish version. The Danish version used lay terms.)

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We found that 44.9% of the girls(n = 179) were able to correctlyassess breast stage (Table 2).Independent of pubertal maturation,girls tended to underestimate breastdevelopment by 1 or 2 stages (52.9%,n = 211). Only 2.3% (n = 9) of girlsoverestimated their pubertaldevelopment by 1 or 2 stages. Thehighest agreement in breast stageswas observed for breast stage B1, at92.4% (n = 73).

Girls who underestimated breaststages B2 (median age = 11.1 vs 11.8years, P = .006) and B3 (median age =12.0 vs 12.4 years, P = .002), but notB4 and B5, were significantly youngerthan girls with correct assessments.Girls who overestimated breast stagetended to be older than girls whomade the correct assessments for B1(median age = 10.7 vs 10.1 years,P = .27) and B2 (median age = 12.0 vs11.8 years, P = .69), but this was notsignificant.

When examining pubic hair stage,66.8% (n = 265) of the girls madecorrect assessments (Table 2).Underestimation by 1 or 2 stages wasfound in 24.7% (n = 98), andoverestimation was found in 8.6%(n = 34). The highest concordancewas observed in PH1 (90.8%, n = 118)and the lowest in PH5 (25.0%, n = 5).

Girls who underestimated pubic hairstage were younger than those whoevaluated correctly (PH2: medianage = 11.2 vs 11.8 years, P = .082;PH3: median age = 12.0 vs 12.5 years,P = .003; PH4: median age = 12.4 vs12.9 years, P = .12; and PH5: medianage = 13.0 vs 14.0 years, P = .008).The girls who overestimated theirpubic hair stage tended to be olderthan those who evaluated correctly,but this was not significant for anystages (data not shown). Nosignificant association was foundbetween BMI and accuracy of breast orpubic hair assessment (data not shown).

Boys’ Self-Assessments

Self-assessment of boys showed onlyfair agreement with clinical

TABLE 2 Girls’ Self-Assessments of Breast and Pubic Hair Development (Tanner Stages 1–5)Versus Clinical Examination as Gold Standard

Clinical Examination Self-Assessment Total N

1 2 3 4 5

Breast stage1 73 (18.3) 6 (1.5) 0 (0) 0 (0) 0 (0) 792 32 (8.0) 63 (15.8) 0 (0) 1 (0.3) 0 (0) 963 7 (1.8) 87 (21.8) 20 (5.0) 2 (0.5) 0 (0) 1164 0 (0) 27 (6.8) 48 (12.0) 22 (5.5) 0 (0) 975 0 (0) 0 (0) 4 (1.0) 6 (1.5) 1 (0.3) 11Total 112 183 72 31 1 399

Pubic hair stage1 118 (29.7) 11 (2.8) 1 (0.3) 0 (0) 0 (0) 1302 21 (5.3) 63 (15.9) 13 (3.3) 1 (0.3) 0 (0) 983 2 (0.5) 19 (4.8) 56 (14.1) 7 (1.8) 0 (0) 844 0 (0) 5 (1.3) 36 (9.1) 23 (5.8) 1 (0.3) 655 0 (0) 0 (0) 6 (1.5) 9 (2.3) 5 (1.3) 20Total 141 98 112 40 6 397

TABLE 3 Boys’ Self-Assessments of Genital and Pubic Hair Development (Tanner Stages 1–5)Versus Clinical Examination as Gold Standard

Clinical Examination Self-Assessment Total N

1 2 3 4 5

Genital stage1 129 (29.5) 91 (20.8) 1 (0.2) 0 (0) 0 (0) 2212 32 (7.3) 62 (14.2) 22 (5.0) 1 (0.2) 0 (0) 1173 2 (0.5) 19 (4.3) 31 (7.1) 8 (1.8) 0 (0) 604 0 (0) 2 (0.5) 10 (2.3) 15 (3.4) 4 (0.9) 315 0 (0) 0 (0) 1 (0.2) 5 (1.1) 2 (0.5) 8Total 163 174 65 29 6 437

Pubic hair stage1 199 (42.4) 69 (14.7) 2 (0.4) 0 (0) 0 (0) 2702 28 (6.0) 69 (14.7) 22 (4.7) 1 (0.2) 0 (0) 1203 0 (0) 6 (1.3) 22 (4.7) 13 (2.8) 2 (0.4) 434 0 (0) 1 (0.2) 1 (0.2) 12 (2.6) 13 (2.8) 275 0 (0) 0 (0) 0 (0) 1 (0.2) 8 (1.7) 9Total 227 145 47 27 23 469

TABLE 4 Agreement Between Physical Examination (Gold Standard) and Parental or Participants’Self-Assessments

Female Male

Puberty Onseta Pubic Hair Breast Puberty Onsetb Pubic Hair Genitals

Parental assessmentk 0.70c 0.41c 0.28c 0.30c 0.28c —

Kendall’s t-b 0.71c 0.46c 0.32c 0.37c 0.29c —

Sensitivity 0.83 0.61 0.86 0.33 0.71 —

Specificity 0.94 0.90 0.61 0.95 0.59 —

Participant’s self-assessmentk 0.69c 0.55c 0.28c 0.46c 0.46c 0.33c

Kendall’s t-b 0.71c 0.80c 0.74c 0.46c 0.70c 0.61c

Sensitivity 0.90 0.91 0.88 0.84 0.86 0.84Specificity 0.93 0.91 0.92 0.61 0.74 0.58

a Onset of puberty defined as breast stage $2 or pubic hair stage $2 for girls.b Onset of puberty defined as genital stage $2 or pubic hair stage $2 for boys.c P , .001.

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examination both for onset of pubertyand pubic hair. Sensitivity was high,and specificity was lower forassessment of both puberty and pubichair development (Table 4). Amongthe boys 73.8% (n = 354) correctlyassessed whether they were inpuberty. Overestimation of pubertalstage was more likely thanunderestimation (17.1%, n = 82 vs9.2%, n = 44, respectively, Table 3).

When examining genital stage, wefound that 54.7% (n = 239) madecorrect evaluations. More boys(n = 127, 29.1%) overestimatedthemselves by 1 or 2 stages, and only71 (16.2%) underestimatedthemselves. The highest agreementwas found in G1 (58.4%, n = 129).

Younger ages at G2 (median age =10.9 vs 11.7 years, P = .001) and G3(median age = 12.4 vs 12.8 years,P = .073) were associated withunderestimation of genital stage. Theboys who overestimated genitalstaging were older than those whoassessed correctly (G1: median age =11.0 vs 10.3 years, P , .001; G2:median age = 12.6 vs 11.7 years,P = .017). There was no correlationbetween BMI and boys’ assessment ofgenital stage (data not shown).

Boys made correct assessments ofpubic hair stage in 66.1% (n = 310),with a tendency to overestimate(n = 122, 26.0%) rather thanunderestimate (n = 37, 7.9%) by 1 to2 stages (Table 3). The highestagreement was observed in PH5(88.8%, n = 8) and the lowest in PH4(44.4%, n = 12).

Younger age was associated withunderestimation of pubic hair stage(PH2: median age = 11.8 vs 12.3years, P = .035). Boys whooverestimated pubic hair developmentwere older than those who assessedcorrectly (PH1: median age = 11.3 vs10.5 years, P , .001; PH2: medianage = 12.8 vs 12.3 years, P = .29; andPH4: median age = 13.6 vs 13.1 years,P = .041). There was no systematicinfluence of BMI on pubic hairassessment in boys (data not shown).

Parental Assessment of Puberty inGirls and Boys

The agreement between clinicalexamination and parental assessmentwas stronger for parents evaluatingdaughters than sons. The agreementbetween evaluation of specificsecondary sex characteristics (onsetof breast development and pubichair) was slight to fair for bothgenders (Table 4). The specificity forassessment of puberty was high inboth daughters and sons (.94 and .95,respectively), but sensitivity waslower, in particular for puberty insons (.33) and pubic hair (.61–.71) inboth genders.

Of the parents, 86.2% (n = 473)assessed correctly whether theirdaughter was in puberty or not,84.3% (n = 280) correctly assessedonset of breast development, and69.6% (n = 229) pubic hair. Parentsunderestimated the onset of pubertyin 11.8% (n = 65), breastdevelopment in 13.0% (n = 43), andpubic hair in 27.4% (n = 90). Theyoverestimated the onset of puberty in2% (n = 11), breast development in2.7% (n = 9), and pubic hairdevelopment in 3% (n = 10).

In boys, 68.4% (n = 422) of parentscorrectly assessed whether they werein puberty, and 67.4% (n = 87)correctly assessed onset of pubic hairgrowth. They underestimated theonset of puberty in 28.7% (n = 177)and pubic hair development in 20.2%(n = 26), and they overestimated theonset of puberty in 2.9% (n = 18)and pubic hair development in 12.4%(n = 16).

DISCUSSION

This large study of 898 Danishchildren shows that self-assessmentand parental assessment of pubertaldevelopment are inaccurate ina substantial number of participantswhen compared with clinicalexamination by trained physicians.Overall, children were slightly moreaccurate than their parents inassessment of whether they had

entered puberty. However, half of thegirls tended to underestimate theirexact breast development stage, andone-quarter also underestimatedpubic hair. In boys, the opposite wasobserved, with approximately one-third overestimating genital or pubichair stage. Parents underestimatedphysical development in up to one-third of their children.

Our findings are in line with someprevious publications, which found anagreement between physician andself-assessment ranging from 48.6%to 52.0% for breast stage, 53.3% to64.0% for pubic hair in girls,17,19 and27.0% to 49.0% for genital stage.15,28

Some studies have reported similar orslightly higher agreement for pubichair in boys, ranging from 58.0% to78.0%.15,19,28 A few studies foundhigh agreement rates for breast stage(86.0%) and pubic hair for girls andboys (80.0% to 93.0%).13,16 To ourknowledge this study is the largestpublished to date, and evaluations bythe child or parent and the examinerwere blinded to pubertal assessmentof the other party. One study13 had veryfew participants (girls 43, boys 23),and half of the children completed thequestionnaires in front of theunblinded physician before theclinical examination. That may haveintroduced a systemic bias towardbetter agreement between ratings.Two previous studies15,16 usedquadratic weighted k, which takesinto account the relative seriousnessof disagreement,29 whereas the k

measure used for our studydifferentiates only betweenagreement and disagreement.

Our participants have been followedsince birth, and many families weretherefore familiar with pubertalexaminations because physicians hadpreviously explained the proceduresbefore they were asked to makepubertal self-assessments. Thus, weexpected a higher agreement betweenclinical examination and self-assessment. However, the childrenmay have encountered difficulties in

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differentiating between theillustrations of pubertal stages (eg,the illustration of B1 could bemisinterpreted as B2 if theexplanatory text was ignored; Fig 2).The high percentage ofmisclassification by self-assessmentindicates that studies in whichpubertal development hasa significant influence on the outcomemust include standardized clinicalexaminations. Overall, it was easierfor children to assess whether therewere any signs of puberty than toevaluate the exact pubertal stagingaccording to Tanner. Parents werebetter at assessing whether theirchildren were in puberty than atdescribing the first physical signs ofdevelopment. The physicians in ourstudy had an interrater variation forassessment of breast stage ofk = 0.78, P , .001, whereas theagreement for onset of breastdevelopment was 100%, probablybecause of the method of palpation ofbreast tissue. This finding is inagreement with earlierpublications.17,30

The girls tended to underestimatebreast and pubic hair stage, which hasalso been shown in previousstudies.19,28,31 In contrast, the boystended to overestimate genital andpubic hair stage, which has also beenreported previously.18–20,31 Age hada significant influence on pubertalself-assessment, in that the children

who underestimated physicaldevelopment tended to be younger,whereas older children tended tooverestimate. We thereforehypothesize that older prepubertalboys overestimate and youngerpubertal girls underestimate becausethey had a preconceived expectationto be at the same development stageas their peers. Girls may also bemisled by the assessment of breastdevelopment as bra size rather thanbreast shape. Only half of the boys inour study were able to assess theirgenital stage, which has also beenshown previously.15,28 One studyusing schematic drawings of Tannerstages similar to ours showed that27% (n = 1150) of the boys reporteda lower genital stage than theyreported 1–1.5 years earlier whenasked to repeat their self-assessments.9 This finding indicatesthat self-assessment is unreliable.

Contrary to our expectations, BMI didnot significantly and systematicallyinfluence self-assessment. High BMIand adiposity can make it difficult todifferentiate lipomastia from breasttissue, which can lead tooverestimation of breastdevelopment.20 Most of our studyparticipants were normal-weightchildren from social class 1 and 2.Social class was determined fromeducational level and self-reportedoccupational status in hierarchicalorder (1 being highest, 5 being

lowest).32 Our data may therefore notbe applicable to children from othersocial classes or have enough statisticalpower to detect influences of high BMIon pubertal self-assessment.

The majority of our participants werein the early stages of puberty, so ourstudy cannot determine whether self-assessment of puberty is moreaccurate once menarche or voicebreak has occurred. One previousstudy with girls in predominantly latepubertal stages17 reported similaragreement rates with other studiesexamining children in early stages ofpuberty,15,19 suggesting that pubertalstage may not influence agreementbetween self-assessment and clinicalexamination.

In conclusion, our data suggest thatpubertal staging by children or theirparents instead of physicalexamination leads to a substantialproportion of misclassification. Girlsand parents tend to underestimateand boys to overestimate theirdevelopment. Thus, studies ofoutcomes that are strongly dependenton precise staging of pubertaldevelopment must ensure correctassessment by standardized clinicalexamination. However, self-assessment may be sufficientlyaccurate for large epidemiologicstudies in which only the distinctionof prepuberty versus puberty isimportant.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: The study was supported by a grant from the Danish Agency for Science, Technology and Innovation (grant 09-067180).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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