Precocious puberty is the early onset of secondary sexual characteristics and pubertal maturation. The most common form, central precocious puberty (CPP), is defined as premature activation of the hypothalamic–pituitary–gonadal (HPG) axis, resulting in the development of secondary sexual traits before age 8 in girls and age 9 in boys. 

The incidence of precocious puberty has increased significantly over the last two decades, with rates rising disproportionately in certain regions. For example, European registry data show increases from 2.6/10,000 to 14.6/10,000 among girls in Denmark between 1998 and 2017. Asian cohorts report much higher rates, with recent Chinese studies finding prevalence rates as high as 14% among girls.  

In the United States, rates of precocious puberty have also increased over the last few decades; however, the prevalence of precocious puberty (specifically defined as pubertal changes before age 8 in girls and age 9 in boys) is below 1% in the US, with girls being substantially more likely than boys to present with CPP. In the US, African American girls experience higher rates of precocious puberty compared to White or Hispanic.

The condition also appears to be more common among children with obesity; rates of CPP among overweight or obese children may be several times higher than in normal-weight peers.  Globally we have observed that the age of pubertal onset is trending downward, potentially related to increasing rates of childhood obesity, environmental exposures, and higher levels of psychosocial stressors.  

Psychiatric Disorders in Children with Precocious Puberty

Dinkelbach and colleagues examined a robust German insurance database of approximately 6.5 million individuals, looking at the prevalence of psychiatric disorders associated with central precocious puberty (CPP). Eligible children (n=1,094) and 5,448 matched controls were identified and followed prospectively from 2010 to 2023. 

The researchers found that children with CPP had a clinically significant increased risk for developing any psychiatric disorder, compared to children with typical pubertal timing: 24.7% in CPP vs. 16.9% in controls (adjusted risk ratio [aRR] 1.48, 95%CI 1.31-1.67).  Rates of the following disorders were increased in children with CPP:

• Depression: 7.5% in CPP vs. 4.6% in controls (aRR 1.73, 95%CI 1.37-2.20)
• Anxiety disorders: 8.0% in CPP vs. 5.7% in controls (aRR 1.45, 95%CI 1.16-1.82)
• Oppositional Defiant Disorder: 8.0% in CPP vs. 4.5% in controls (aRR 1.76, 95%CI 1.39-2.23).
• ADHD: 11.2% in CPP vs. 7.3% in controls (aRR 1.53, 95%CI 1.27-1.86)

While it is possible that precocious puberty increases risk for psychiatric illness, the relationship is more complex:

• Temporal Patterns: Rates of ODD were elevated even before CPP diagnosis, suggesting some degree of bidirectional relationship or shared risk factors. For depression and ADHD, increased incidence rates persisted up to eight years following CPP diagnosis.
• Sex Differences: While CPP is much more prevalent in girls, this study—unlike previous work—also found increased psychiatric risk in boys with CPP. 
• Bidirectional Risks: Exploratory analyses revealed that  preexisting psychiatric illness  increased risk for subsequent CPP, supporting a complex interplay between psychological morbidity and pubertal timing.
• Persistence of Risk: Psychiatric vulnerability persisted for years after normalization of pubertal development, underscoring the need for long-term psychiatric surveillance in affected children.

How Does Precocious Puberty Increase Psychiatric Risk?

The relationship between early pubertal timing and psychiatric morbidity likely involves several mutually reinforcing mechanisms:

• Maturation Mismatch: The mismatch between physical maturity and emotional/cognitive developmental capacity may create psychological distress, social alienation, and vulnerability to peer bullying, especially in girls.
• Endocrine Effects: Abrupt increases in sex hormones and their effects on the developing brain might directly influence mood, behavior, and cognition.
• Preexisting Factors: Early adversity and psychiatric morbidity may contribute in some children to earlier puberty, possibly via stress-induced dysregulation of the HPG axis.
• Bidirectionality: Not only does precocious puberty confer heightened risk for new psychiatric disorders, but early mental health problems may also accelerate pubertal timing.

Clinical Implications 

Precocious puberty, while not common, is increasingly recognized for its long-lasting psychiatric sequelae, with affected children at heightened risk for depression, anxiety, ODD, and ADHD, risks that endure well after puberty ends.  This is the largest study looking at the risk of psychiatric illness in this population.

• Screening for Psychiatric Illness: Children diagnosed with CPP should be considered at high risk for psychiatric disorders. Proactive screening is warranted.
• Long-Term Follow-Up: Because psychiatric risk persists for years beyond normalizing puberty; sustained monitoring and early intervention can greatly improve outcomes.
• Family Education: Providers should educate families about the psychological aspects of CPP, offering support and referral to mental health resources as needed.
• Further Research: More studies are needed to delineate the neurobiological, hormonal, and psychosocial mechanisms linking early puberty and psychiatric illness, in order to refine prevention and treatment strategies.

Ruta Nonacs, MD PhD

Reference:

Dinkelbach L, Grasemann C, Kiewert C, Leikeim L, Schmidt B, Hirtz R. Central precocious puberty and psychiatric disorders. JAMA Netw Open. 2025 Jun 2;8(6):e2516679.