SMR ASSESSMENT AND ITS CLINICAL ISSUES
Dr. Sukanta Chatterjee, MD *, Dr. Nilanjana Pramanick**, Dr. Gobinda Mondal ***
Professor & Head, Department of Pediatrics, Medical College, Kolkata International Member of Society for Adolescent Medicine (USA) *, --**, --***
Sexual Maturity Rating (SMR) refers to a quantitative scale of anatomic changes an adolescent undergoes in visible sexual characteristics e.g., genital organ and pubic hair in boys, breast development and pubic hair changes in girls. Originally, described by J M Tanner in 1960s is still recognized as an important tool to measure physical maturation of a child towards an adult.(1) The details of SMR stages I - V for boys and girls in each item mentioned above is available in literature for clinical use.(2) Besides physical changes, a series of psychological changes also occur in adolescents towards fulfilling the developmental task to become an adult as described by Erik Erikson.(3) WHO defines adolescent between 10-19 years of age as most of the changes of puberty are complete by this age. Depending upon the degree of changes the period is further divided into early (10-13 yrs) adolescence.(4)

The onset and progress of normal pubertal growth in an individual may vary widely with chronological age in different family and social settings. On the other hand, it is closely related to SMR stage of the individual. Therefore an adolescent's maturation will be better assessed by sexual maturity rating stages or 'SMR age' than 'chronological age'. Besides sexual organ growth the height spurt, weight gain, adolescent BMI changes (increase in boys, decrease in girls), haematocrit changes (39% at SMR 1, 43% when SMR V in boys) and ECG changes are more closely related to SMR age .(5, 8) Normal developmental task of an adolescent are achieved at a wide range of chronological age, but it is more related to SMR stages of the individual e.g., the body image and physical activity.(6) Boys with behavior problems had significantly advanced Tanner SMR stages than comparison group.(7) Children at higher SMR stages than their peers were more likely to experiment with smoking.(9) Eating Disorders like 'bulimia' were more common in early maturing (SMR) girls and in off-time (early or late) maturing boys.(10) Depression amongst girls are higher with early maturing pubertal status.(11) Headache, musculoskeletal pain were seen more commonly in off-time pubertal developer (early or late) than that of on-time ones.(12) Early maturing (SMR) girls reported more interest than on-time/later maturing ones in seeing sexual contents in movies, magazines.(13) Early developing boys (SMR) had more aggressiveness/unruliness, more girl friends and other sexually active behavior.(14)

Therefore, the need of determining the SMR stage of an adolescent and its comparison with chronological age is of great clinical importance to understand the etiology and to plan management of both physical and development issues in them. Examination of SMR is always embarrassing to an adolescent due to undressing. Getting consent for the examination is difficult and the process itself might reduce friendliness of the clinician or the clinic. To overcome this negative impact on this very important clinical tool, self-assessment of SMR staging was tried by many workers like 'breast cancer screening' self-examination.(15) The reliability of self-assessment of SMR were compared to clinical examination by many authors.(16-24) The reliability is more in public hair staging in self-examination than in breast/penis staging. This was attributed to existing high or low body image perceptions in the adolescents.(25) It could also be due to less absolute criteria of differentiation between SMR stage II / III or IV / V in breast or penis staging unlike public hair staging where every stage has its absolute criteria in Tanner Scale. The examination should be done after getting the consent of the adolescent and preferably not in front of the parents as recommended for pelvic examination.(26)

In our clinic setting, we found adolescents more comfortable in absence of parents. Best way we obtained consent for SMR examination was by proposing that we want to examine whether you are growing at per in your sexual maturity. The adolescents who prefer self-examination were explained about Tanner staging by demonstrating photographs. Many of them subsequently could be convinced to consent for clinical examination. However considering the issues of reliability of self-examination, it is recommended that clinical examination is preferred but could be deferred and replaced by self examination till the consent is obtained. The self-examination could be a part of annual screening.

Percent agreement of self-assessment and physician assessment of SMR recording at Adolescent Health Clinic, Medical College Kolkata are shown in table form:


Percent agreement on public hair by physician and adolescent in boys and girls (n = 69)
SMR Stage % agreement
I 75% (n = 8)
II 55.5% (n = 9)
III 55% (n = 20)
IV 52.4% (n = 21)
V 70.3% (n = 11)


Key message: Relation of SMR staging and symptoms/signs of adolescent growth and psychological development should be worked out as a routine. It will explore the cause and effect relation on many occasions and could avoid unnecessary investigations and interventions. On the other hand, it can guide for early useful intervention. Examination may be embarrassing but useful and clinicians have to look for and create opportunities for it.
References :
  1. Tanner J M. Growth at Adolescents. 2 nd edition. Oxford : Blackwell Scientific Publication. 1962, p. 32-38.
  2. Robert D. Needlman. Adolescence : growth and development in Nelson Text Book of Pediatrics. Behrman RE, Kliegman RM, Jenson HP (eds)17 th edition. Saunders.2004, p. 53-55.
  3. Personality theory. Erik Erikson by Dr. C. George Boeree http://www.ship.edu /~cgboeree/erikson.html (accessed on 30.07.05.)
  4. WHO. Adolescent friendly health services in Sough East Asia Region, Report of a regional consultation 9-14 February 2004, Bali, Indonesia, New Delhi:SEARO;August 2004:p.3.
  5. Agarwal KN, Sazena A, Bonsal AK, Agarwal DK, Physical growth assessment in adolescence. Indian Pediatr 2001;38:1217-35.
  6. Taveras EM, Rifas-Shiman SL, Field AE, Colditz GA, Gilman MW. The influence of wanting to look like media figures on adolescent physical activity. J Adolesc Health 2004;35:41-50.
  7. Rauch SP, Brack CJ, Orr DP. School based, short-term group treatment for behaviorally disturbed young adolescent males : a pilot intervention. J Sch Health 1987;57:19-22.
  8. Stafford EM, Weir MR, Pearl W, Imai W, Schydlower M, Gregory G. Sexual maturity rating : a marker for effects of pubertal maturation on the adolescent electrocardiogram Pediatrics 1989;83:565-9.
  9. Joanne S. Harrell FANN et al, Smoking initiation in youth Journal of Adolescent Health, Volume 23, Issue 5, p 271-279 (November 1998).
  10. Rittakerttu Kaltiala-Heino Dr. Med. Sci. Matti Rimpel Dr. Med. Sci et al. Early puberty and early sexual activity are associated with bulimic-type eating pathology in middle adolescence. Journal of Adolescent Health, Volume 28, Issue 4, p 346-352 (April 2001).
  11. Chris Hayward M.P.H., Ian H Gotlib et al. Ethnic differences in the association between pubertal status and symptoms of depression in adolescent girls. Journal 25, Issue 2, p 143-149 (August 1999).
  12. Hyekyun Rhee. Relation between physical symptoms and pubertal development. Journal of Pediatric Health Care, Volume 19, Issue 2, p 95-103 (March 2005).
  13. Jane D. Brown, Carolyn Tucker Halplern, Kelly Ledin L'Engle. Mass media as a sexual super peer for early maturing girls. Journal of Adolescent Hea, Volume 36, Issue 5, p 420-427 (May 2005).
  14. Kenneth Kim, Peter K. Smith, Anna-Lisa Palermiti. Conflict in childhood and reproductive development. Evolution and human Behavior, Volume 18, Issue 2, p 109-142 (March 1997).
  15. Jenkins RR. Delivery of health care to adolescents. In : Nelson text book of Pediatrics Behrman RE, Klingman RM, Jenson HB (eds), 17 th Ed., Saunders, 2004 : p 43-45.
  16. Neinstein LS. Adolescent self-assessment of sexual maturation : reassessment and evaluation in a mixed ethnic urban population. Clin Pediatr (Phila) 1982;21:482-4.
  17. Schlossberger NM, Turner RA, Irwin CE Jr. Validity of self-report of pubertal maturation in early adolescents. J Adolesc health. 1992 Mar;13(2):p 109-13.
  18. Williums RI, Cheyne KL, Houtkooper LK, Lobman TG. Adolescent self-assessment of sexual maturation; effects of fatness and actual sexual maturation stage. J Adolesc Health Care. 1988 Nov; 9(6):480-2.
  19. Duck PM, Litt IF, Gross RT. Adolescents' self-assessment of sexual maturation. Pediatrics. 1980 Dec; 66(6):918-20.
  20. Berg-Killy K, Erdes L. Self-assessment of sexual maturity by mid-adolescents based on a global question. Acta Paediatr. 1997 Jan ; 86(1):10-17.
  21. Daniel WA Jr. Practical use of sex maturity ratings in adolescents. Practitioner. 1975 Feb ; 214 (1280) : 209-12.
How to Cite URL :
MD C S D, Pramanick N D, Mondal G D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=87
Disclaimer: The information given by www.pediatriconcall.com is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. The site does not guarantee the accuracy or authenticity of the information. Use of any information is solely at the user's own risk. The appearance of advertisement or product information in the various section in the website does not constitute an endorsement or approval by Pediatric Oncall of the quality or value of the said product or of claims made by its manufacturer.
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.