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The SPSS 17.0 program was used. Categorical variables were expressed in percentage and frequency. Continuous variables are expressed as arithmetic mean, standard deviation, median, minimum, maximum values. The normal distribution suitability of the variables was tested by the Kolmogorov-Smirnov test. Mann-Whitney U test, Chi-square and Fisher's exact tests were used in the analyzes. p <0.05 significance level.

Bulgular

The two groups were similar in terms of age, mother age, father age, mother education, father education variables (p <0.05).
The two groups were similar in terms of CPRS, CTRS, CDS and Pier-Harris scales distributions (p> 0.05).
The puberty scale scores of the puberte procox group were significantly higher than the normal group scores (median value 16.5 vs. 11, z = -4.035, p <0.001) and Body Sensitivity Scale scores were significantly lower (median 175 vs. 185.5, z = -2.537, p = 0.011) (see Table 1).
Table 1. Comparison of demographic and clinical characteristics of puberty precox and normal girls

 Total (n=120) Puberte precox (n=56) Normal (n=64) Statistics M (min-max) Avarage (SD) M (min-max) Avarage (SD) M (min-max) Avarage (SD) z p Age (year) 8 (7-9) 7.9 (0.5) 8 (7-9) 7.9 (0.4) 8 (7-9) 8.0 (0.6) -1.185 0.236 Mother age (year) 34 (24-48) 34.9 (5.5) 35 (27-48) 34.9 (5.5) 34 (24-48) 34.3 (5.5) -1.182 0.237 Father age (year) 36 (27-55) 37.7 (5.8) 36.5 (28-55) 38.3 (5.9) 36 (27-55) 37.2 (5.6) -1.173 0.241 Mother education (year) 11 (4-15) 9.9 (2.7) 11 (5-15) 9.8 (2.8) 11 (4-15) 9.9 (2.6) -0.246 0.806 Father education (year) 11 (5-15) 10.4 (2.3) 11 (5-15) 10.4 (2.3) 11 (5-15) 10.4 (2.3) -0.255 0.799 CPRS 14 (2-55) 14.9 (7.7) 14.5 (2-55) 15.6 (8.6) 11.5 (3-31) 14.2 (6.9) -0.991 0.321 CTRS 19 (4-48) 20.2 (7.7) 19.5 (4-40) 20.3 (6.8) 18 (10-48) 20.2 (8.4) -1.057 0.291 CDQ 6 (2-32) 7.5 (5.0) 5 (2-24) 7.3 (5.5) 6.5 (3-32) 7.7 (4.6) -1.541 0.123 SCARED 13 (1-66) 15 (9.8) 16.5 (1-66) 18.5 (11.7) 11 (3-40) 12 (6.3) -4.035 0.000 Body sensation 180 (140-200) 179.4 (12.5) 175 (140-200) 176.2 (14.5) 185.5 (155-195) 182.2 (9.7) -2.537 0.011 Pier-Harris 73 (57-79) 72.8 (4.2) 72.5 (57-79) 71.9 (4.8) 75 (61-79) 73.6 (3.6) -1.767 0.077

M: median, min: minimum, max: maximum

Avarage: mean, SD: standart deviatition

CPRS: Conner’s parent rating scale, CTRS: Conner’s teacher rating scale

CDQ: child depression scale

SCARED: anxiety screening scale

At least one psychiatric disorder was found to be significantly higher in the puberty precox group (32.1% vs. 10.9%), x2 = 8.143, p = 0.004.

CPRS-POSITIVE was significantly higher in the puberty precox group (67.9 vs. 48.4%), x2 = 4.609, p = 0.032

LOW-POSITIVE was significantly higher in the puberty precox group (17.9% vs. 4.7%), x2 = 5.363, p = 0.021

(See table 2).

Table 2. Distribution of categorical variables

 Total (n=120) Puberte precox (n=56) Normal (n=64) Statistics n (%) n (%) n (%) X2 p Tanner Stage Stage 1 64 (53.3) 0 (0.0) 64 (100.0) 154.775 0.000 Stage 2 51 (42.5) 51 (91.1) 0 (0.0) Stage 3 5 (4.2) 5 (8.9) 0 (0.0) Diagnoses No comorbidity 95 (79.2) 38 (67.9) 57 (89.1) 8.143 0.004 At least one diagnosis 25 (20.8) 18 (32.1) 7 (10.9) primer diagnose: ADHD 8 (6.7) 5 (8.9) 3 (4.7) ADHD 0 0 0 ADHD + ODD 5 (4.2) 2 (3.6) 3 (4.7) ADHD + anx 2 (1.7) 2 (3.6) 0 ADHD + anX+dep 1 (0.8) 1 (1.8) 0 Primer depression 4 (3.3) 3 (5.4) 1 (1.6) depression 3 (2.5) 2 (3.6) 1 (1.6) ADHD + ODD 1 (0.8) 1 (1.8) 0 Primer anxiety 7 (5.8) 5 (8.9) 2 (3.1) Tek anksiyete 4 (3.3) 3 (5.4) 1 (1.6) Ank+ADHD+ODD 2 (1.7) 1 (1.8) 1 (1.6) Ank + ODD 1 (0.8) 1 (1.8) 0 Primer ODD 6 (5.0) 5 (8.9) 1 (1.6) Ölçekler CPRS-POZ?T?F 69 (57.5) 38 (67.9) 31 (48.4) 4.609 0.032 CTRS-POZ?T?F 10 (8.3) 5 (8.9) 5 (7.8) 0.049 0.825 ÇDÖ-POZ?T?F 5 (4.2) 4 (7.1) 1 (1.6) 2.329 0.183* SCARED-POZ?T?F 13 (10.8) 10 (17.9) 3 (4.7) 5.363 0.021

ODD: oppitional defiant disorders, BD: behavior disorder

*: Fisher’s exact test

CPRS: Conner’s parent rating scale, CTRS: Conner’s teacher rating scale

CDQ: child depression scale

SCARED: anxiety screening scale

When comorbid psychiatric disorders were classified as inhalation disorders (depression, anxiety) and out-of-body impairments (dehB, kokgb), inhalation or outflow impairment was found to be higher in pubertal precox cases than control group cases (see table 3).

Table 3. Comparison of distribution of binge-throw disorders (presence of depression or anxiety disorder) and out-break disorders (presence of dehB or kokGB) between two groups

 Total (n=120) Puberte precox (n=56) Normal (n=64) Statistics n (%) n (%) n (%) X2 p Internelizan 14 (11.9) 11 (20.4) 3 (4.7) 6.889 0.009 Externalizan 18 (15.0) 13 (23.2) 5 (7.8) 5.557 0.018 ADHD 11 (9.2) 7 (12.5) 4 (6.3) 1.401 0.237 Anx 10 (8.3) 8 (14.3) 2 (3.1) 4.870 0.027 Depr 5 (4.2) 4 (7.1) 1 (1.6) 2.329 0.183* OPD 15 (12.5) 10 (17.9) 5 (7.8) 2.755 0.097

*: Fisher’s exact test

Write an original article to someone using this data. Psychiatric comorbidity in children with precocious puberta.

Introduction

Puberty is the development of secondary sexual characteristics like breast development in girls and pubic hair and penile enlargement in boys. The precocious puberty is the early onset of puberty in girls and boys. (Kaplowitz P, Silverman L, 2014). It is also seen in high percentage of cases that this is generally due to activation of gonadotropic axis with pulsatile secretion of gonadotropin secreting hormone which ultimately leads to high level of Follicular secretion hormone. This leads to early development of secondary sexual characteristics. The age limit for girls is considered as 8 years for girls and 9 years for boys. There are two types of precocious puberty, one is central which is dependent on gonadotropin and the other is gonadotropin independent type. The girls suffering from precocious puberty suffer from a gain of height which is very variable. This makes them look physically different. (Carel JC et al, 2004).

The early maturing children have high susceptibility to mental, emotional, cognitive disorders as they have to face negative influences from their social group because of them being more physically mature and look elder.  This leads them to surrender to various behavioral and emotional problems leading to high aggression, depression, anxiety and substance use. (Mrug S et al, 2014). The previous literature also supports the relation between pubertal maturation and social anxiety. (Blumenthal et al.,2009; Deardorff et al., 2007; Ge et al., 2006; Blumenthal et al.,2011). There are also past evidences that suggest that the early maturing kids experience elevated anxiety level. (Reardon et al., 2009 and Deardorff et al., 2007). Thus the present study was conducted with an aim to evaluate the level of psychiatric symptoms faced by the children suffering from pubertaprecocs.

Objectives:
• To evaluate and compare the phsychological problems faced by the children suffering from puberta precocs
• To associate the phsychological problems faced by the children suffering from puberta precocs and healthy children with various categorical variables

Methodology:

The present study was undertaken in University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital" Child and Adolescent Psychiatry Department and Child Endocrinology Clinic. The data was collected between January, 2017 and October, 2017. The sample was randomly selected using simple random numbers. The sample chosen was 120 in numbers consisting of 56 children suffering from p.precocs and 64 were healthy controls. Patients admitted to the pediatric endocrine polyclinic with complaints of early adolescence were randomly selected and directed to child and adolescent psychiatry (tanner stage 2 and 3). A consecutive approach was used to reduce bias and it included all referred patients. The control group consisting of healthy children also had similar age and gender as the treated group.

The exclusion criteria werethe patients with intellectual abilities, drug users who can influence the hormonal balance, chronic illness, genetic diseases, etc.

The children were interviewed though DSM-V which is a universal tool for psychiatric diagnoses, (American Psychiatric Association, 2018). These children were later then assessed for their psychiatric problems through the use of different assessment tools like: Screen for Child Anxiety Related Emotional Disorders (SCARED) used for assessing the anxiety, social and phobic disorder, (Birmaher B et al, 2015) CPRS: Conner’s parent rating scale is the common tool for assessing the children behavior problems from the parents’ perception, (Conners CK et al, 1998), Conners Teacher Rating Scale (CTRS) is a commonly used research and clinical tool for assessing children's behavior in the classroom (Conners CK et al, 1998), Child Depression Scale is used to assess the depression in children ( Tisher M, 2007)The Piers-Harris Children’s Self-Concept Scale – Second Edition (Piers-Harris 2) is a self assessment 60 item questionnaire to analyze the self concept of children (Community-University Partnership for the Study of Children, Youth, and Families, 2011) and Body Perception Scale which is used to measure how satisfied the children are with their body functions (Chen W Y, 2013).

The Local Ethics Committee of Ankara Children’s Health and Diseases Hematology-Oncology Training Research Hospital approved the study. All families were informed regarding the study and the corresponding informed consents were taken in adherence to the Declaration of Helsinki requirements.

The data was analysed using SPSS version 17 where in the Categorical variables were expressed in percentage and frequency. Continuous variables are expressed as arithmetic mean, standard deviation, median, minimum, maximum values. The normal distribution suitability of the variables was tested by the Kolmogorov-Smirnov test. Mann-Whitney U test, Chi-square and Fisher's exact tests were used in the analysis for evaluating the difference in psychiatric problems faced by cases and controls. The p value was kept at 0.05 significance level

Results

The two groups were similar in terms of age, mother age, father age, mother education, father education variables (p <0.05).

The two groups were similar in terms of CPRS, CTRS, CDS and Pier-Harris scales distributions (p> 0.05).

The puberty scale scores of the puberteprocox group were significantly higher than the normal group scores (median value 16.5 vs. 11, z = -4.035, p <0.001) and Body Sensitivity Scale scores were significantly lower (median 175 vs. 185.5, z = -2.537, p = 0.011) (see Table 1).

Table 1. Comparison of demographic and clinical characteristics of puberty precox and healthy children

 Variables Total (n=120) Puberte precox (n=56) Normal (n=64) Statistics ( z value) P value M (min-max) Average (SD) M (min-max) Average (SD) M (min-max) Average (SD) Age (year) 8 (7-9) 7.9 (0.5) 8 (7-9) 7.9 (0.4) 8 (7-9) 8.0 (0.6) -1.185 0.236 Mother age (year) 34 (24-48) 34.9 (5.5) 35 (27-48) 34.9 (5.5) 34 (24-48) 34.3 (5.5) -1.182 0.237 Father age (year) 36 (27-55) 37.7 (5.8) 36.5 (28-55) 38.3 (5.9) 36 (27-55) 37.2 (5.6) -1.173 0.241 Mother education (year) 11 (4-15) 9.9 (2.7) 11 (5-15) 9.8 (2.8) 11 (4-15) 9.9 (2.6) -0.246 0.806 Father education (year) 11 (5-15) 10.4 (2.3) 11 (5-15) 10.4 (2.3) 11 (5-15) 10.4 (2.3) -0.255 0.799 CPRS 14 (2-55) 14.9 (7.7) 14.5 (2-55) 15.6 (8.6) 11.5 (3-31) 14.2 (6.9) -0.991 0.321 CTRS 19 (4-48) 20.2 (7.7) 19.5 (4-40) 20.3 (6.8) 18 (10-48) 20.2 (8.4) -1.057 0.291 CDQ 6 (2-32) 7.5 (5.0) 5 (2-24) 7.3 (5.5) 6.5 (3-32) 7.7 (4.6) -1.541 0.123 SCARED 13 (1-66) 15 (9.8) 16.5 (1-66) 18.5 (11.7) 11 (3-40) 12 (6.3) -4.035 0.000 Body sensation 180 (140-200) 179.4 (12.5) 175 (140-200) 176.2 (14.5) 185.5 (155-195) 182.2 (9.7) -2.537 0.011 Pier-Harris 73 (57-79) 72.8 (4.2) 72.5 (57-79) 71.9 (4.8) 75 (61-79) 73.6 (3.6) -1.767 0.077

M: median, min: minimum, max: maximum

Average: mean, SD: standard deviation

CPRS: Conner’s parent rating scale, CTRS: Conner’s teacher rating scale

CDQ: child depression scale

SCARED: anxiety screening scale

Table 2 shows that at least one psychiatric disorder was found to be significantly higher in the puberty precox group (32.1% vs. 10.9%), Chi Sq value = 8.143, p = 0.004. CPRS-POSITIVE was also significantly higher in the puberty precox group (67.9 vs. 48.4%), Chi Sq Value = 4.609, p = 0.032. Low Positive was significantly higher in the puberty precox group (17.9% vs. 4.7%), Chi Sq. value = 5.363, p = 0.021.

Table 2. Distribution of categorical variables

 Variables Total (n=120) Puberte precox (n=56) Normal (n=64) Statistics Chi Square P Value n (%) n (%) n (%) Tanner Stage Stage 1 64 (53.3) 0 (0.0) 64 (100.0) 154.775 0.000 Stage 2 51 (42.5) 51 (91.1) 0 (0.0) Stage 3 5 (4.2) 5 (8.9) 0 (0.0) Diagnoses No comorbidity 95 (79.2) 38 (67.9) 57 (89.1) 8.143 0.004 At least one diagnosis 25 (20.8) 18 (32.1) 7 (10.9) primer diagnose: ADHD 8 (6.7) 5 (8.9) 3 (4.7) Not applicable Not Applicable ADHD 0 0 0 ADHD + ODD 5 (4.2) 2 (3.6) 3 (4.7) ADHD + anx 2 (1.7) 2 (3.6) 0 ADHD + anx+dep 1 (0.8) 1 (1.8) 0 Primer depression 4 (3.3) 3 (5.4) 1 (1.6) Not applicable Not Applicable depression 3 (2.5) 2 (3.6) 1 (1.6) ADHD + ODD 1 (0.8) 1 (1.8) 0 Primer anxiety 7 (5.8) 5 (8.9) 2 (3.1) Not applicable Not Applicable Tekanksiyete 4 (3.3) 3 (5.4) 1 (1.6) Ank+ADHD+ODD 2 (1.7) 1 (1.8) 1 (1.6) Ank + ODD 1 (0.8) 1 (1.8) 0 Primer ODD 6 (5.0) 5 (8.9) 1 (1.6) Not applicable Not Applicable Ölçekler CPRS-POZ?T?F 69 (57.5) 38 (67.9) 31 (48.4) CTRS-POZ?T?F 10 (8.3) 5 (8.9) 5 (7.8) 0.049 0.825 ÇDÖ-POZ?T?F 5 (4.2) 4 (7.1) 1 (1.6) 2.329 0.183* SCARED-POZ?T?F 13 (10.8) 10 (17.9) 3 (4.7) 5.363 0.021

ODD: oppitional defiant disorders, BD: behavior disorder

*: Fisher’s exact test

CPRS: Conner’s parent rating scale, CTRS: Conner’s teacher rating scale

CDQ: child depression scale

SCARED: anxiety screening scale

Table 3 shows the When comorbid psychiatric disorders were classified as  internalization (depression, anxiety) and externalization (ADHD, ODD) disorders, inhalation and outflow impairment was found to be higher in pubertal precox cases than control group cases

Table 3.shows the comparison of distribution of binge-throw disorders (presence of depression or anxiety disorder) and out-break disorders (presence of dehB or kokGB) between two groups

 Variables Total (n=120) Puberte precox (n=56) Normal (n=64) Statistics ( Chi Sq) P value n (%) n (%) n (%) Internelizan 14 (11.9) 11 (20.4) 3 (4.7) 6.889 0.009 Externalizan 18 (15.0) 13 (23.2) 5 (7.8) 5.557 0.018 ADHD 11 (9.2) 7 (12.5) 4 (6.3) 1.401 0.237 Anx 10 (8.3) 8 (14.3) 2 (3.1) 4.870 0.027 Depr 5 (4.2) 4 (7.1) 1 (1.6) 2.329 0.183* OPD 15 (12.5) 10 (17.9) 5 (7.8) 2.755 0.097

*: Fisher’s exact test

Discussion

The present study shows that the psychological problems faced by children suffering from precocious puberty are high. They are more vulnerable to various psychiatric disorders. Similar findings were also reported by Mrug S et al, 2013 and Blumenthal H et al, 2011.

Carel J et al, 2004 also reported that the prime concern for any endocrinologist is to check for the central nervous system or gonadal neoplasm, however apart from that due to accelerated growth and bone maturation the reduced height of the children becomes an issue of concern for them.

The previous literature shows that the girls with early puberty but without precocious puberty shows problems like high level of aggression, conflict with parents, anti social behavior which ultimately leads to drop out from school. The same study also revealed that these girls have high prevalence of teen pregnancy. (Graber J A et al, 2004;Sattin H et al, 1990; Wadhera S et al, 1997;Ickovicks J R, 1992).

The girls who had early onset of menstrual cycle showed increased use of alcohol and drug intake, experienced early sexual relationships and more prone to commitment of crimes. ( Rovet J, 1983;Johnassen T, Ritzen E M, 2005). The prevalence of psycho somatic problems was more in case of early menstruating girls (Ehrdart AA, 1983).

The present study also shows that the psychiatric problems are more seen in case of girls diagnosed with precocious puberty. The assessment through different tools revealed the same result. The results of studies ( Waylen A, 2004; Kim J H, 2009) shows that as the girls with precocious puberty show early physical changes than their peer they suffer more from low self esteem, loneliness and depression.

However, studies ( Sonis W A et al, 1985; Mazur T et al, 1991) concluded that the girls with precocious puberty does not experience any psychological problems but whatever the psychiatric disturbances are reported can be due to dysphoria.

The present study also shows that the internalization and externalization problems are higher in cases of children suffering from precocious puberty. This was similarly reported in (Kim EY and Lee M I, 2012) where their results showed that there was high score of externalization problems and total behavioral, thought, and attentional problem group suffering from precocious puberty.

These patients as discussed suffer from low self esteem and low self confidence due to increase in serum DHEA level while signs of depression, aggression was not correlated with serum DHEA levels ( Mensah F K et al, 2013).

The present study tried to analyze the psychological problems through the use of various scales meant for the purpose of assessing the psychiatric problems faced by these children. The use of different scale helps in evaluating the problem through different means for better addressal of the situation. This study revealed that there is the presence of psychological and behavioral problems faced by these girls that needs to be early recognized and addressed as that is the main cause of concern for both patients and their parents.

The present study tries to evaluate the psychological problems faced by the puberta precocs children through different scales, which addresses their problems through different perspectives. The study also compares these problems with the healthy children of the same age and gender to get a better representation of the problem. The previous literature also highlights the same apart from few literatures that have contrasting results which may be because they have taken both boys and girls in their sample. The study focuses on girls only which is one of the limitations. The study can be extended to other gender and other areas. A comparative analysis between the boys and girls, urban and rural area would enable to solve the problem individually.

Conclusion

Early puberty brings with it changes in the physical appearance of children which makes them different from their peers leading to lower self esteem and self confidence. This results in a lot of negative physical outcomes. The study also highlights through the use of different assessment scale that there is presence of psychological problems in children suffering from puberta precocs. The challenge is to identify the various factors that affect the psychopathology of these children and make attempt to solve them. The health providers should also be watchful in attending these cases as apart from rendering medical treatment, these children need regular counslling conditions and motivational sessions to boost their self esteem and confidence.

References
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