103 Growth, Puberty, and Development
103.1 Introduction
Adolescence marks one of the most dynamic phases of human development, characterised by profound physical, hormonal, cognitive, and psychosocial transitions. In Ghana and across West Africa, these changes occur within diverse cultural, nutritional, and socioeconomic environments that shape how young people grow and mature. Understanding normal adolescent development is essential for clinicians, as abnormalities of growth or puberty often reflect underlying medical, nutritional, or psychosocial challenges that may be overlooked without a structured clinical approach. For paediatricians and trainees, adolescence represents a period where medical concerns intersect strongly with social context, requiring sensitivity, broad clinical reasoning, and holistic care.
103.2 Growth and its Regulation
Physical growth during adolescence is influenced by a complex interaction of genetic potential, hormonal regulation, nutrition, emotional well-being, and chronic disease burden. Growth hormone and IGF-1 function as the principal drivers of linear growth, but their action depends heavily on normal thyroid function, adequate caloric intake, and the presence of sex steroids. During the adolescent years, the activation of the hypothalamic–pituitary–gonadal axis accelerates growth, resulting in the well-recognised pubertal growth spurt. Girls typically experience this acceleration between ages 10 and 12, while boys follow approximately two years later. This phase of rapid height gain is eventually curtailed when rising sex steroids promote epiphyseal closure.
In many parts of Ghana, growth patterns reflect broader societal influences. Stunting remains prevalent in some rural and low-income communities, influenced by early childhood undernutrition, repeated infections, and limited dietary diversity. Conversely, in urban centres such as Accra and Kumasi, improved socioeconomic conditions and changing food environments have led to increasing rates of adolescent overweight and obesity, which may shift both the timing and pattern of pubertal development.
103.3 Physiology and Sequence of Puberty
Puberty begins when pulsatile GnRH activity reawakens after childhood quiescence, stimulating the secretion of LH and FSH and driving gonadal maturation. In girls, breast development is usually the first overt sign, followed by the appearance of pubic and axillary hair, acceleration in linear growth, and eventually menarche. Boys typically begin with testicular enlargement, followed by pubic hair growth, deepening of the voice, increased muscle mass, and their own growth spurt.
Although the overall sequence of events is predictable, the tempo may vary considerably among individuals. Clinicians commonly rely on Tanner staging to assess the degree of physical maturation, but interpretation always requires contextual understanding—particularly in regions where nutritional status and chronic illnesses may influence timing. HIV, renal disease, poorly controlled asthma requiring long-term steroids, and haemoglobinopathies are among the conditions known to delay puberty in West African adolescents.
103.4 Disorders of Pubertal Timing
Abnormal pubertal timing may present either as precocious puberty or delayed puberty, both of which demand careful clinical evaluation. Pubertal onset before 8 years in girls or 9 years in boys is considered precocious and may arise from early activation of the HPG axis or from peripheral sources of sex steroids. Although many cases of central precocious puberty in girls are idiopathic, boys are more likely to have an underlying pathological cause. In Ghana, clinicians must also consider environmental endocrine disruptors, although evidence remains emerging.
Delayed puberty, conversely, often reflects constitutional delay—especially in boys—but may also signal chronic undernutrition, chronic systemic disease, hypothalamic–pituitary dysfunction, or primary gonadal failure. Emotional stress, socio-economic deprivation, and strenuous athletic training may all influence timing. Distinguishing constitutional delay from pathological hypogonadism is critical, as the latter requires targeted hormonal therapy while the former may simply need reassurance and observation.
103.6 Clinical Assessment
A comprehensive evaluation requires more than a physical examination. Growth should be assessed using accurate anthropometric measurements plotted on age- and sex-appropriate growth charts. Height velocity—rather than absolute height—is often the earliest marker of abnormal growth. A detailed history of nutrition, chronic illness, family growth patterns, and psychosocial factors provides important context.
Examination should include Tanner staging, identification of dysmorphic features, evaluation for chronic disease, and assessment of secondary sexual characteristics. In girls, menstrual history gives valuable insight into endocrine and nutritional health. For all adolescents, a psychosocial review—guided by frameworks such as HEADSSS—supports the recognition of mental health concerns, risk behaviours, and environmental stressors.
When abnormalities are suspected, investigations may include complete blood count, inflammatory markers, thyroid function tests, adrenal and gonadal hormone assays, and IGF-1 levels. Bone age assessment provides objective evidence of growth potential and pubertal stage. Imaging studies such as pelvic ultrasound or brain MRI are reserved for cases where structural pathology is suspected.
103.7 Management Approaches
Management begins with education. Many concerns arise from misinterpretation of normal developmental changes—whether physical (e.g., breast asymmetry, nocturnal emissions), emotional, or social. Clear, sensitive explanation helps adolescents and their caregivers navigate this period with confidence.
For disorders of puberty, treatment is directed at the underlying cause. Central precocious puberty is effectively managed with GnRH analogues, which slow progression and preserve adult height. Peripheral causes require targeted treatment, such as surgery for adrenal or gonadal tumours or hormonal control in congenital adrenal hyperplasia. Delayed puberty due to constitutional delay often needs only reassurance, though short courses of low-dose sex steroid therapy may be used to initiate pubertal progression in selected cases. When chronic disease or malnutrition is responsible, optimising general health becomes the priority.
Psychosocial support is equally vital. Adolescents facing early or delayed puberty may experience social isolation, anxiety, or poor self-esteem. Clinicians should adopt a holistic approach, involving school counsellors, psychologists, and social workers when appropriate.
103.8 Complications
Abnormal growth and pubertal disorders can lead to several long-term consequences. These may include reduced adult height, compromised bone mineral density, menstrual irregularities, fertility concerns, and persistent psychological distress. Early or late physical maturation may also predispose adolescents to risk behaviours, academic challenges, or body-image disturbances. Detecting these complications early allows clinicians to intervene and mitigate long-term harm.
103.9 Prevention and Health Promotion
Promoting healthy adolescent development begins in early childhood. Ensuring adequate nutrition, preventing chronic infections, and providing timely vaccination and routine health checks establish a foundation for healthy puberty. During adolescence, health promotion efforts should address lifestyle habits—including diet, physical activity, and screen use—and reinforce the importance of sleep, stress management, and social support.
In Ghana and similar settings, creating adolescent-friendly health services remains essential. Facilities should protect confidentiality, provide non-judgmental counselling, and integrate mental health support. Community engagement, including working with schools, churches, and families, strengthens these efforts and ensures adolescents receive consistent guidance across the environments they navigate daily.
103.10 Key Points
- Adolescence is a period of rapid physical and psychosocial development shaped by biological, cultural, and environmental influences.
- Normal growth and puberty follow predictable patterns, but interpretation must account for nutritional status and chronic illness.
- Disorders of pubertal timing require careful assessment to distinguish normal variants from pathological causes.
- Cognitive and emotional development is as significant as physical maturation and must be incorporated into clinical evaluation.
- Holistic care—including medical, psychological, and social support—promotes healthy transition into adulthood.
103.11 Further Reading
- Neinstein LS, Gordon CM, Katzman DK, et al. Adolescent Health Care: A Practical Guide.
- Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet.
- World Health Organization. Adolescent Health: Key Facts.
- Tanner JM. Growth and maturation during adolescence.
- Ghana Health Service. National Adolescent Health Strategy.