Paeds · adolescent-and-young-adult-medicine
Normal puberty and adolescent development
Also known as Normal puberty · Tanner staging · Pubertal development · Adolescent growth and development · Normal variants of puberty · Gonadarche and adrenarche
A fellowship approach to normal puberty and adolescent development: the reactivated HPG axis, Tanner staging of breast/genital and pubic hair development, the sex-specific sequence and timing of events, the coupled growth spurt and brain changes, the normal variants, the referral thresholds for abnormal timing, and counselling across ANZ, UK, US and Canada.
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Target exams
Red flags
- Girls with signs before 8 years or boys with testicular enlargement before 9 years (precocious)
- Rapidly progressive puberty crossing more than two Tanner stages in 6 to 12 months
- New neurological signs with a pubertal finding: headache, visual field loss, gelastic seizures, morning vomiting
- Sudden virilisation in a girl: clitoromegaly, deepening voice, rapid muscle bulk
- Girls with no breast development by 13 years or boys with no testicular growth by 14 years (delayed)
- Galactorrhoea, thyroid storm, or Cushingoid features accompanying a pubertal sign
- Delayed puberty with anosmia or other pituitary-deficiency signs
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Adolescent and young adult medicine — normal growth and pubertal development
- Learning Goal 19 — Adolescent and young adult medicine: assess normal puberty and recognise variants and deviations requiring referral
- Current 2026 PREP curriculum — apply knowledge of normal pubertal physiology and Tanner staging in clinical assessment
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment of growth and puberty
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management of growth concerns
- Adolescent and Young Adult Medicine 4–7
- Growth, Development and Behaviour
- Written Exam: normal pubertal milestones, staging and referral thresholds
- Short Cases — growth and pubertal assessment
- Long Cases — delayed or early puberty in the context of chronic disease
- Communication stations — counselling a young person and family about pubertal timing
- Level 2 — Growth and Puberty: Recognises normal pubertal development and staging
- Level 3 — Growth and Endocrinology: Identifies abnormal pubertal timing and refers appropriately
- Health promotion and illness prevention — adolescent development
- General Paediatrics: stages puberty accurately using Tanner criteria and counsels on normal variation
- Foundation of Practice (FOP) — normal growth, puberty and adolescent development
- Applied Knowledge in Practice (AKP) — recognising normal variants versus abnormal pubertal timing
- TAS — endocrine and growth milestones
- Development — pubertal assessment and staging
- History and Communication — counselling on pubertal timing and normal variation
- Clinical — short case on growth and puberty
- General Pediatrics Content Outline — Domain 3: Adolescent Care (5%)
- General Pediatrics Content Outline — Domain 1: Growth and Development — pubertal milestones and Tanner staging
- General Pediatrics EPA 3: Providing well-child and adolescent care including pubertal assessment
- General Pediatrics Content Outline — Domain 5: Endocrine — normal versus abnormal puberty
- Patient Care 1: History and Physical Examination — pubertal staging
- Medical Knowledge 2: Diagnostic Decision Making — normal variants of puberty
- Medical Knowledge: Endocrine — physiology of puberty and growth
- Systems-Based Practice 4: Transitions in Care — adolescent development and referral
- Medical Expert — normal pubertal physiology and clinical staging
- Development, Behaviour and Mental Health (10–15%) — adolescent development
- Pediatrics: Foundations EPA — Assessing growth and pubertal development
- Communicator — counselling young people and families on pubertal timing
Overview & Definition
A 13-year-old boy is brought in because he is "the smallest in the class" and "hasn't started." His father grew late and reached his adult height at 19. You measure testicular volumes of 3 mL, plot a height that is tracking along the third centile at a normal velocity, and order a bone age that reads two years behind his chronological age. The answer is not a disease. It is the single most common reason boys present with delayed puberty: constitutional delay of growth and puberty. The skill is recognising what is normal, explaining it well, and reserving referral for the few who are not. [4] [6]
Puberty is the biological transition from a prepubertal child to a reproductively mature young adult, driven by the reactivation of the hypothalamic–pituitary–gonadal (HPG) axis. Adolescence is the broader social and developmental phase that puberty sits inside — identity formation, increasing autonomy, peer orientation and the move toward adult roles. Puberty is measurable; adolescence is lived. A clinician who can stage puberty but cannot talk to a young person about what it means has only done half the job. [10] [11]
The clinical task has three layers. First, describe what you see: which Tanner stage, in what sequence, at what age, progressing at what tempo. Second, classify whether that pattern is normal, a normal variant, or outside the band. Third, act: reassure and monitor, or refer with the right urgency. Most young people you see will sit in the first two categories. The danger is not over-calling the common — it is missing the rare one who needs a brain scan. [3] [5]
The three clinical questions of any pubertal assessment
- 1
What stage?
Tanner B/G stage and PH stage separately; Prader orchidometer in boys; growth chart and velocity.
- 2
Is the timing normal?
Girls 8–13 yr onset, boys 9–14 yr; menarche 10–15 yr; within band = reassure or variant.
- 3
Does it need referral?
Outside the band, rapid progression, CNS or endocrine red flags, or psychosocial crisis → paediatric endocrine.
References18ShowHide
- [1]Marshall WA, Tanner JM Variations in pattern of pubertal changes in girls. Archives of disease in childhood, 1969.PMID 5785179
- [2]Marshall WA, Tanner JM Variations in the pattern of pubertal changes in boys. Archives of disease in childhood, 1970.PMID 5440182
- [3]Carel JC, Léger J Clinical practice. Precocious puberty. The New England journal of medicine, 2008.PMID 18509122
- [4]Palmert MR, Dunkel L Clinical practice. Delayed puberty. The New England journal of medicine, 2012.PMID 22296078
- [5]Latronico AC, Brito VN, Carel JC Causes, diagnosis, and treatment of central precocious puberty. The lancet diabetes & endocrinology, 2016.PMID 26852255
- [6]Harrington J, Palmert MR An Approach to the Patient With Delayed Puberty. The Journal of clinical endocrinology and metabolism, 2022.PMID 35100608
- [7]Lopez-Rodriguez D, Franssen D, Heger S, Parent AS Endocrine-disrupting chemicals and their effects on puberty. Best practice & research. Clinical endocrinology & metabolism, 2021.PMID 34563408
- [8]Herbison AE Control of puberty onset and fertility by gonadotropin-releasing hormone neurons. Nature reviews. Endocrinology, 2016.PMID 27199290
- [9]Navarro VM Metabolic regulation of kisspeptin - the link between energy balance and reproduction. Nature reviews. Endocrinology, 2020.PMID 32427949
- [10]Casey BJ, Jones RM, Hare TA The adolescent brain. Annals of the New York Academy of Sciences, 2008.PMID 18400927
- [11]Steinberg L A Social Neuroscience Perspective on Adolescent Risk-Taking. Developmental review, 2008.PMID 18509515
- [12]Petersen AC, Crockett L, Richards M, Boxer A A self-report measure of pubertal status: Reliability, validity, and initial norms. Journal of youth and adolescence, 1988.PMID 24277579
- [13]Sørensen K, Mouritsen A, Aksglaede L, et al. Recent secular trends in pubertal timing: implications for evaluation and diagnosis of precocious puberty. Hormone research in paediatrics, 2012.PMID 22508036
- [14]Apter D, Hermanson E Update on female pubertal development. Current opinion in obstetrics & gynecology, 2002.PMID 12401974
- [15]Smith CE, Biro FM Pubertal Development: What's Normal/What's Not. Clinical obstetrics and gynecology, 2020.PMID 32482957
- [16]Sørensen K, Hagen CP, Juul A Higher peak height velocity in early maturing girls depends on insulin rather than fat mass or IGF-I. European journal of endocrinology, 2024.PMID 39292994
- [17]Lopez-Rodriguez D, Franssen D, Bakker J, et al. Cellular and molecular features of EDC exposure: consequences for the GnRH network. Nature reviews. Endocrinology, 2021.PMID 33288917
- [18]Pan D, Lin C A systematic review and meta-analysis of the self-reported Pubertal Development Scale's applicability. Journal of pediatric endocrinology & metabolism, 2025.PMID 40256953