Early Breast Development in Girls: Anxiety and Depression Look Alike Whether Puberty Is Central or Not

When a young girl develops breasts before her eighth birthday, parents face a cascade of worry: Is this puberty starting too soon? Will it affect her growth, her hormones, her future? And increasingly, pediatric researchers are asking a quieter but equally urgent question: What is this doing to her mind? A new study from Türkiye, published in Frontiers in Psychiatry, offers one of the most methodically careful answers yet, and its central finding is striking: whether the early breast development reflects true central precocious puberty or a benign, isolated variant, the psychological burden appears remarkably similar.

Central precocious puberty, or CPP, is the full hormonal event. The hypothalamic–pituitary–gonadal axis, the master control system that normally lies dormant through childhood, switches on prematurely, driving progressive pubertal development before age 8 in girls. Isolated premature thelarche, or IPT, is different: breast tissue appears early, but without other progressive pubertal signs and typically without sustained activation of that same central hormonal axis. Clinically, the distinction matters enormously—CPP may warrant GnRH agonist treatment to preserve growth potential, while IPT often requires only monitoring. Psychologically, the new research suggests, the two conditions may be far harder to tell apart.

The study, led by child psychiatrist Burak Kamış and pediatric endocrinologists Semine Özdemir Dilek and Gürkan Tarçın, recruited 50 girls with a mean age of about 8.3 years at a single Turkish hospital. Eighteen had idiopathic CPP, confirmed biochemically by a GnRH stimulation test showing a stimulated peak luteinizing hormone concentration of at least 5 IU/L—evidence that the central pubertal machinery had genuinely activated. Thirty-two had IPT, meaning isolated breast development without biochemical evidence of central axis activation. Crucially, every participant in the CPP group also underwent contrast-enhanced brain and pituitary MRI, and no organic cause was found, ensuring the comparison focused on the idiopathic form of the condition.

The diagnostic rigor is what sets this study apart from much of the existing literature. All girls underwent a standardized endocrinological evaluation including basal LH, FSH, and estradiol measurements, bone-age assessment from a hand and wrist radiograph using the Greulich and Pyle atlas, pelvic ultrasonography, and the same GnRH stimulation protocol applied identically in both groups. Anthropometric data—height, weight, and body mass index converted to standard deviation scores using Turkish reference values—showed no significant differences between the groups in growth parameters, BMI, or the proportion of girls with overweight or obesity. This matters because body composition itself can influence both hormone levels and psychological well-being, so matching the groups on these variables strengthens the comparison.

On the psychological side, the researchers deployed a battery of validated Turkish-language instruments, all completed by the children themselves on the same day as their endocrinological evaluation. Anxiety symptoms were measured with the 41-item Screen for Child Anxiety Related Emotional Disorders (SCARED) and the Revised Child Anxiety and Depression Scale–Child Version (RCADS-CV). Depressive symptoms were assessed with the Children’s Depression Inventory (CDI). Health-related quality of life was captured with the Pediatric Quality of Life Inventory Version 4.0, which spans physical, emotional, social, and school functioning. In girls with CPP, all psychological assessments were completed before any GnRH agonist treatment began, avoiding the confounding effect of comparing pretreatment with post-treatment states.

The headline result: after applying Benjamini–Hochberg false-discovery-rate correction—a statistical procedure designed to control the expected proportion of false positives when running many comparisons simultaneously—no between-group differences in anxiety, depressive symptoms, or quality of life remained statistically significant. Clinically elevated SCARED screening scores, indicating anxiety symptoms warranting further assessment, appeared in 38.9 percent of girls with CPP and 53.1 percent of girls with IPT. Elevated CDI depression screening scores occurred in 11.1 percent and 18.8 percent, respectively. Neither difference reached statistical significance. The IPT group actually trended slightly higher on both measures, echoing a 2024 study by Donbaloglu and Bostan that reported greater anxiety–depression burden in girls with premature thelarche than in those with idiopathic CPP—a finding that contradicts the intuitive assumption that full central puberty must be more distressing than a benign variant.

But the study’s most consequential finding lies not in the CPP–IPT comparison at all, but in what emerged when the two groups were combined. Across all 50 girls, psychological symptom scores correlated inversely with quality-of-life scores, with Spearman’s rank correlation coefficients ranging from −0.568 to −0.720, all highly significant. In plain terms: the more anxious and depressed a girl felt, the worse she rated her own physical, emotional, social, and school functioning. An exploratory hierarchical regression model, adjusted for endocrine phenotype, BMI standard deviation score, and symptom duration, found that SCARED and CDI scores together explained nearly 50 percent of the additional variance in quality-of-life scores beyond what the endocrine variables accounted for. The endocrine phenotype itself showed no significant adjusted association with quality of life.

The authors are careful, appropriately so, about what these numbers do and do not prove. All measures were child self-report instruments, creating the possibility of common-method variance—the statistical artifact that arises when the same respondent rates both the predictor and the outcome. There is also conceptual overlap between internalizing symptoms and quality-of-life domains, particularly emotional functioning. Distress may drive poorer perceived functioning, impaired functioning may intensify distress, or both may stem from shared psychosocial vulnerabilities such as family stress or peer experiences that the study did not measure. The absence of a healthy-control group means the researchers cannot determine whether either clinical phenotype carries greater psychological burden than girls without early breast development. And the small, single-center sample of 50 girls, with unequal group sizes, limits statistical precision.

Longitudinal evidence adds another layer of caution. Recent nationwide cohort studies from Germany and Denmark, published in JAMA Network Open and the Journal of Clinical Endocrinology and Metabolism, reported elevated risks of several psychiatric disorders among individuals with CPP compared with population referents over extended follow-up. Those studies examined clinically recorded disorders over years; the present study examined questionnaire scores at a single moment. The absence of cross-sectional CPP–IPT differences does not contradict the longitudinal findings, nor does it demonstrate that the two groups will follow similar psychological trajectories. A cross-sectional snapshot cannot capture how symptoms evolve as puberty progresses, treatment begins, or social contexts shift.

What the study does offer is a clear clinical signal: elevated anxiety and depression screening scores appeared in both diagnostic groups, suggesting that emotional well-being deserves attention whenever a girl presents with early breast development, regardless of whether her endocrine evaluation points to central precocious puberty or isolated premature thelarche. The screening thresholds used—SCARED at 25 or above and CDI at 19 or above—are cutoffs for further assessment, not psychiatric diagnoses, and the authors emphasize that clinical evaluation should consider symptom persistence and functional impact rather than questionnaire scores alone. Larger longitudinal studies with healthy comparison groups, repeated assessments, and measures of family and peer experiences will be needed to clarify whether and how early pubertal activation shapes psychological development over time. For now, the message for clinicians and parents alike is that the mind and the endocrine system in these young patients are best understood together—and that the psychological weight of early breast development may not depend on which hormonal story lies behind it.

Subject of Research: Anxiety and depressive symptoms and health-related quality of life in girls with central precocious puberty versus isolated premature thelarche

Article Title: Anxiety and depressive symptoms and health-related quality of life in girls with central precocious puberty versus isolated premature thelarche: a comparative cross-sectional study

Article References: Kamış, B., Özdemir Dilek, S., & Tarçın, G. (2026). Anxiety and depressive symptoms and health-related quality of life in girls with central precocious puberty versus isolated premature thelarche: a comparative cross-sectional study. Frontiers in Psychiatry, 17, Article 1971843. https://doi.org/10.3389/fpsyt.2026.1971843

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1971843

Keywords: central precocious puberty, isolated premature thelarche, anxiety, depressive symptoms, health-related quality of life, pediatric endocrinology, child mental health, depressive, symptoms, health-related, quality, life