Association between Puberty, Age, and Behavior in Children and Youth with Autism Spectrum Disorder: Data from the Pond Network

Background: Puberty is often cited as a cause of challenging behaviour in children with autism spectrum disorder (ASD), although there is little evidence to support this.

Objectives: The objective of this study was to determine the association between pubertal status, age, and internalizing/externalizing behavior in children and youth with ASD.

Methods: This was a cross-sectional study using data from the Province of Ontario Neurodevelopmental Disorders network and included children and youth with ASD aged 8-19. All participants’ caregivers completed the Child Behavior Checklist (CBCL). Participants or caregivers reported Tanner stage of puberty. Participants were grouped into three pubertal stages: pre-pubertal (Tanner 1), pubertal (Tanner 2-4), and post-pubertal (Tanner 5). The influence of pubertal stage on CBCL internalizing and externalizing behavior scores was assessed using multivariable linear regression controlling for age. Because the sample consisted of more males than females, separate analyses were done for each sex, with the primary analysis for males and a secondary analysis for females.

Results: Three hundred fifty-seven participants (277 males and 80 females) were included. In males, an interaction term between pubertal stage and age was not significantly associated with internalizing behavior (p=0.07); however, within the pre-pubertal and pubertal stages, there was a significant positive association with age and internalizing behavior, with older males in these pubertal stages demonstrating higher levels of internalizing behavior (pre-pubertal p=0.0009; pubertal p=0.007; Figure 1). There was a non-significant negative association between age and internalizing behavior in the post-pubertal sample (p=0.7). There were significantly lower externalizing behavior levels in male participants with each successive pubertal stage (p=0.0001) with a significant positive association between age and externalizing behavior (p=0.0009), meaning that older males within that pubertal stage had higher levels of externalizing behavior (Figure 2). Internalizing behavior in female participants showed a borderline significant positive association with age (p=0.04). There was no significant independent effect of puberty on internalizing behavior for female participants (p=0.5). No significant associations were found between externalizing behavior and age (p=0.3) or pubertal stage (p=0.7) in female participants.

Conclusions: Older males within pre-pubertal and pubertal stages demonstrate higher levels of internalizing behavior and older males in all pubertal stages demonstrate higher levels of externalizing behavior, raising the possibility of a protective effect of earlier puberty. Levels of externalizing behavior for males are lower in each successive pubertal stage. Females demonstrated higher levels of internalizing behavior with increasing age; however, further study is needed on larger samples.