Environmental Injustice: Focus on Pediatric Neurodevelopmental Disorders

1. Environmental Injustice:Focus on Pediatric Neurodevelopmental Disorders Lawrence D. Rosen, MD Chair, Integrative Pediatrics Council lrosen@integrativepeds.org

2. The State of Children�s Health Cancer Prematurity Asthma/allergies Obesity/Diabetes Neurodevelopmental and Mental Health Disorders �The new morbidities� -Our current disease-care system is not set up to handle these well No incentives for wellness promotion and prevention (precautionary principle) 1. Cancer continues to be the leading cause of death by disease in children. The age-adjusted annual incidence of cancer in children increased from 129 to 166 cases per million children between 1975 and 2002. (especially endocrine related) 2. Prematurity: One in eight babies is born prematurily, an increase of nearly 31 percent since 1981. A lack of prenatal care and poor nutrition may account for 40% of premature births in developed countries. Preterm birth contributes to more than one-third of all infant deaths and costs the U.S. more than $26 billion per year. 3. Asthma is the most prevalent chronic disease affecting American children, leading to 15 million missed days of school per year. From 1980 to 2004, the percentage of children with asthma has more than doubled, from 3.6 percent to 8.5 percent. Food allergies also greatly on the rise. 4. One in three adolescents are overweight or at risk of becoming overweight. One in six youths ages 6-19 years are overweight, a 45 percent increase in the past 10 years alone. Type 2 diabetes rates, directly related to the obesity epidemic, are rapidly increasing in U.S. youth. Of those children newly diagnosed with diabetes, the percentage with type 2 has risen from less than 5 percent to nearly 50 percent in a ten year period. This disease disproportionately affects American Indian, African American, Mexican American, and Pacific Islander youth. 5. Neurodevelopmental disorders/Mental health - false distinction �The new morbidities� -Our current disease-care system is not set up to handle these well No incentives for wellness promotion and prevention (precautionary principle) 1. Cancer continues to be the leading cause of death by disease in children. The age-adjusted annual incidence of cancer in children increased from 129 to 166 cases per million children between 1975 and 2002. (especially endocrine related) 2. Prematurity: One in eight babies is born prematurily, an increase of nearly 31 percent since 1981. A lack of prenatal care and poor nutrition may account for 40% of premature births in developed countries. Preterm birth contributes to more than one-third of all infant deaths and costs the U.S. more than $26 billion per year. 3. Asthma is the most prevalent chronic disease affecting American children, leading to 15 million missed days of school per year. From 1980 to 2004, the percentage of children with asthma has more than doubled, from 3.6 percent to 8.5 percent. Food allergies also greatly on the rise. 4. One in three adolescents are overweight or at risk of becoming overweight. One in six youths ages 6-19 years are overweight, a 45 percent increase in the past 10 years alone. Type 2 diabetes rates, directly related to the obesity epidemic, are rapidly increasing in U.S. youth. Of those children newly diagnosed with diabetes, the percentage with type 2 has risen from less than 5 percent to nearly 50 percent in a ten year period. This disease disproportionately affects American Indian, African American, Mexican American, and Pacific Islander youth. 5. Neurodevelopmental disorders/Mental health - false distinction

3. Epidemiology 1/150 in US with ASD 1/100 in NJ with ASD 1/60 boys in NJ with ASD 1/12 in US with ADHD 1/6 with neurodevelopmental disorder Sharp increases also seen for depression, bipolar disorder, anxiety

4. Children as a priority �The health of our children is one of the most important investments we can make and should be among our top priorities.� -The Children�s Environmental Health Network �The true measure of a nation�s standing is how well it attends to its children � their health and safety, their material security, their education and socialization, and their sense of being loved, valued, and included in the families and societies into which they are born.� - UNICEF, Child poverty in perspective: An overview of child well-being in rich countries, Innocenti Report Card 7, 2007

5. How are we doing? 2007 study by the United Nations through UNICEF, titled �Child poverty in perspective: An overview of child well-being in rich countries � A comprehensive assessment of the lives and well-being of children and adolescents in the economically advanced nations,� found that twenty other affluent countries outranked the U.S. on the subject of the welfare of its children.22 The U.S., considered by many to possess the world�s top health care system, ranked at the bottom of this U.N. survey. How could this be? In an interview with National Public Radio (NPR), one of the study�s authors, Jonathan Bradshaw, lamented, �We've failed to invest in child health, in child education, in child care� It's the result of neglect, which other countries have not done� they've just spent more on their children, despite the fact they're not as rich as we are.�23 2007 study by the United Nations through UNICEF, titled �Child poverty in perspective: An overview of child well-being in rich countries � A comprehensive assessment of the lives and well-being of children and adolescents in the economically advanced nations,� found that twenty other affluent countries outranked the U.S. on the subject of the welfare of its children.22 The U.S., considered by many to possess the world�s top health care system, ranked at the bottom of this U.N. survey. How could this be? In an interview with National Public Radio (NPR), one of the study�s authors, Jonathan Bradshaw, lamented, �We've failed to invest in child health, in child education, in child care� It's the result of neglect, which other countries have not done� they've just spent more on their children, despite the fact they're not as rich as we are.�23

6. Environmental Injustice �Environmental Justice is the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies.� (U.S. EPA) Injustice is done when there exist health disparities based on these same factors.

7. Why Children? �Children are not little adults� - CHE LDDI statement, November 2007 Neuroendocrine/immune development Differences in exposure to environmental toxins Doubly exposed (pre- and postnatal) Differences in excretion No political voice CHE LDDI statement (more later): Nervous systems, endocrine, immune systems developing - more susceptible to interference (MANY enviro stressors affect multiple systems, and systems are synergistic) Exposure: Hand to mouth, closer to ground Per body weight, eat, drink and breathe in greater amounts than adults Exposed prenatally and postnatally (formula - milk if not organic, plastics or BF; and foods) Differences in excretion CHE LDDI statement (more later): Nervous systems, endocrine, immune systems developing - more susceptible to interference (MANY enviro stressors affect multiple systems, and systems are synergistic) Exposure: Hand to mouth, closer to ground Per body weight, eat, drink and breathe in greater amounts than adults Exposed prenatally and postnatally (formula - milk if not organic, plastics or BF; and foods) Differences in excretion

8. The most vulnerable of the vulnerable �Many of the children who are most heavily exposed in our society to environmental toxins are the same children who are poor, the same children who have either no access or inadequate access to medical care.� - Dr. Philip Landrigan

9. CHE LDDI Scientific Consensus Statement Collaborative on Health and the Environment�s Learning and Developmental Disabilities Initiative (LDDI): Scientific Consensus Statement on Environmental Agents Associated with Neurodevelopmental DisordersCollaborative on Health and the Environment�s Learning and Developmental Disabilities Initiative (LDDI): Scientific Consensus Statement on Environmental Agents Associated with Neurodevelopmental Disorders

10. Environmental Triggers Genetic/Epigenetic Interaction Timing (prenatal and postnatal) Mixtures/multiple exposures List of potential stressors Malnutrition Stress Infections, ant-infectives, vaccines Toxins (air, land, water) Malnutrition (iron and lead) Stress (see living on earth SITE) Infections, ant-infectives, vaccines Toxins (air, land, water) Malnutrition (iron and lead) Stress (see living on earth SITE) Infections, ant-infectives, vaccines Toxins (air, land, water)

11. Host Factors Exposure + poor excretion = environment and genetics Mitochondrial theories Perfect Storm scenario Exposure + poor excretion = environment and genetics Mitochondrial theories Perfect Storm scenario

12. The Iceberg Model The interaction of host and environment, both biochemically and psychologically (Scott Shannon and the Ecology of the Child) Neuroimmune and GI interconnections, the brain as downstream (Martha Herbert)The interaction of host and environment, both biochemically and psychologically (Scott Shannon and the Ecology of the Child) Neuroimmune and GI interconnections, the brain as downstream (Martha Herbert)

13. Specific Examples Lead Polychlorinated biphenyls (PCBs) Polycyclic aromatic hydrocarbons (PAHs) Nutrition Stress

14. Lead Even very low levels a/w ND differences BLLs >=5 mcg/dL among 1- to 5-year-old children was 25.6% BLLs >=5 mcg/dL 46.8% of non-Hispanic black children 27.9% of Mexican American children 18.7% of non-Hispanic white children Older housing and poverty is greater risk Compared with non-Hispanic white children, non-Hispanic black children were 3 times more likely to have a BLL 5-10 mcg/dl, 7 times more likely to have a BLL of 10-20 mcg/dL, and 13.5 times more likely to have a BLL >=20 mcg/dL Jusko TA, Henderson CR, Lanphear BP, Cory-Slechta DA, Parsons PJ, Canfield RL. Blood lead concentrations < 10 microg/dL and child intelligence at 6 years of age. Environ Health Perspect. 2008 Feb;116(2):243-8. Bernard SM, McGeehin MA: Prevalence of blood lead levels >or= 5 micro g/dL among US children 1 to 5 years of age and socioeconomic and demographic factors associated with blood of lead levels 5 to 10 micro g/dL, Third National Health and Nutrition Examination Survey, 1988-1994. Pediatrics. 2003 Dec;112(6 Pt 1):1308-13. Overall prevalence of BLLs >or=5 micro g/dL among 1- to 5-year-old children was 25.6%, although most (76%) of these children had BLLs <10 micro g/dL. Children with BLLs >or=5 micro g/dL included 46.8% of non-Hispanic black children, 27.9% of Mexican American children, and 18.7% of non-Hispanic white children; 42.5% of children in housing built before 1946, 38.9% of children in housing built between 1946 and 1973, and 14.1% of children in housing built after 1973 had BLLs >or=5 micro g/dL. Compared with non-Hispanic white children, non-Hispanic black children were 3 times more likely to have a BLL >or=5 but <10 micro g/dL, 7 times more likely to have a BLL of 10-20 micro g/dL, and 13.5 times more likely to have a BLL >or=20 micro g/dL. Similar increases in the association between risk factor and BLL were seen with respect to other known risk factors including age of housing, region of the country, and poverty.Jusko TA, Henderson CR, Lanphear BP, Cory-Slechta DA, Parsons PJ, Canfield RL. Blood lead concentrations < 10 microg/dL and child intelligence at 6 years of age. Environ Health Perspect. 2008 Feb;116(2):243-8. Bernard SM, McGeehin MA: Prevalence of blood lead levels >or= 5 micro g/dL among US children 1 to 5 years of age and socioeconomic and demographic factors associated with blood of lead levels 5 to 10 micro g/dL, Third National Health and Nutrition Examination Survey, 1988-1994. Pediatrics. 2003 Dec;112(6 Pt 1):1308-13. Overall prevalence of BLLs >or=5 micro g/dL among 1- to 5-year-old children was 25.6%, although most (76%) of these children had BLLs <10 micro g/dL. Children with BLLs >or=5 micro g/dL included 46.8% of non-Hispanic black children, 27.9% of Mexican American children, and 18.7% of non-Hispanic white children; 42.5% of children in housing built before 1946, 38.9% of children in housing built between 1946 and 1973, and 14.1% of children in housing built after 1973 had BLLs >or=5 micro g/dL. Compared with non-Hispanic white children, non-Hispanic black children were 3 times more likely to have a BLL >or=5 but <10 micro g/dL, 7 times more likely to have a BLL of 10-20 micro g/dL, and 13.5 times more likely to have a BLL >or=20 micro g/dL. Similar increases in the association between risk factor and BLL were seen with respect to other known risk factors including age of housing, region of the country, and poverty.

15. PCBs PCB exposure affects development (multiple sources in LDDI statement) Native American children at high risk: multigenerational exposure �The most notable finding was the significant negative relationship between PCB levels and two separate measures of long term memory. There was also a negative relationship with a measure of comprehension and knowledge.� - Newman et al: PCBs and cognitive functioning of Mohawk adolescents. Neurotoxicol Teratol. 2006 Newman J, Aucompaugh AG, Schell LM, Denham M, DeCaprio AP, Gallo MV, Ravenscroft J, Kao CC, Hanover MR, David D, Jacobs AM, Tarbell AM, Worswick P; Akwesasne Task Force on the Environment. PCBs and cognitive functioning of Mohawk adolescents. Neurotoxicol Teratol. 2006 Jul-Aug;28(4):439-45. Epub 2006 Jun 30. This paper reports on the relationships between the cognitive functioning and PCB current body burdens of adolescents in the Mohawk Nation of Akwesasne where there is concern about industrial pollution of the environment. Three cognitive tests (Woodcock Johnson-Revised, Test of Memory and Learning, and Ravens Progressive Matrices) provide 13 subtests that allow a variety of cognitive outcomes to be assessed. A summary measure of PCB level was created from the congeners detected in at least 50% of the participants. The most notable finding was the significant negative relationship between PCB levels and two separate measures of long term memory. There was also a negative relationship with a measure of comprehension and knowledge. Significant relationships were not large, but provide evidence of subtle negative effects of PCB exposure.Newman J, Aucompaugh AG, Schell LM, Denham M, DeCaprio AP, Gallo MV, Ravenscroft J, Kao CC, Hanover MR, David D, Jacobs AM, Tarbell AM, Worswick P; Akwesasne Task Force on the Environment. PCBs and cognitive functioning of Mohawk adolescents. Neurotoxicol Teratol. 2006 Jul-Aug;28(4):439-45. Epub 2006 Jun 30. This paper reports on the relationships between the cognitive functioning and PCB current body burdens of adolescents in the Mohawk Nation of Akwesasne where there is concern about industrial pollution of the environment. Three cognitive tests (Woodcock Johnson-Revised, Test of Memory and Learning, and Ravens Progressive Matrices) provide 13 subtests that allow a variety of cognitive outcomes to be assessed. A summary measure of PCB level was created from the congeners detected in at least 50% of the participants. The most notable finding was the significant negative relationship between PCB levels and two separate measures of long term memory. There was also a negative relationship with a measure of comprehension and knowledge. Significant relationships were not large, but provide evidence of subtle negative effects of PCB exposure.

16. PAHs Long known as carcinogens, more recently recognized as neurotoxic Children > risk due to inhalation Inner city > exposure Prenatal exposure affects neurodevelopment (Perera NYC studies) High prenatal exposure to PAHs was associated with lower mental development index at age 3 The odds of cognitive developmental delay were also significantly greater for children with high prenatal exposure Chuang JC, Callahan PJ, Lyu CW, Wilson NK. Polycyclic aromatic hydrocarbon exposures of children in low-income families. J Expo Anal Environ Epidemiol. 1999 Mar-Apr;9(2):85-98. Perera FP, Rauh V, Whyatt RM, Tsai WY, Tang D, Diaz D, Hoepner L, Barr D, Tu YH, Camann D, Kinney P. Effect of prenatal exposure to airborne polycyclic aromatic hydrocarbons on neurodevelopment in the first 3 years of life among inner-city children. Environ Health Perspect. 2006 Aug;114(8):1287-92. Chuang JC, Callahan PJ, Lyu CW, Wilson NK. Polycyclic aromatic hydrocarbon exposures of children in low-income families. J Expo Anal Environ Epidemiol. 1999 Mar-Apr;9(2):85-98. Perera FP, Rauh V, Whyatt RM, Tsai WY, Tang D, Diaz D, Hoepner L, Barr D, Tu YH, Camann D, Kinney P. Effect of prenatal exposure to airborne polycyclic aromatic hydrocarbons on neurodevelopment in the first 3 years of life among inner-city children. Environ Health Perspect. 2006 Aug;114(8):1287-92.

17. Malnutrition Iron Zinc/Copper Vitamin D Essential fatty acids (omega 3�s) Iron (deficiency leads to increased lead absorption) Zinc/Copper (and MT and mercury excretion) Vitamin D (and depression)(protects cells from ox stress) Essential fatty acids (omega 3�s) and mood disorders, ADHD, ASDIron (deficiency leads to increased lead absorption) Zinc/Copper (and MT and mercury excretion) Vitamin D (and depression)(protects cells from ox stress) Essential fatty acids (omega 3�s) and mood disorders, ADHD, ASD

18. Stress of Poverty Multiple stressors (financial, social) Increased rates of maternal depression Alters neurohormones Dr. Martha Farah (Center for Cognitive Neuroscience, U-Penn): �Stress is Neurotoxic� Martha Farah, Director of the Center for Cognitive Neuroscience, University of Pennsylvania: �Stress is neurotoxic� it impacts the developing nervous system. In addition, there are factors like the greater incidence of maternal depression in poor families, and we know from studies of people at all income levels that maternal depression is actually very bad for child development. When moms are depressed they pay less attention to the kids. They engage with them less, they are less, you know, warm and involved, because they're depressed.� Sources: http://psych.upenn.edu/~mfarah/ http://www.ft.com/cms/s/0/62c45126-dc1f-11dc-bc82-0000779fd2ac.html?nclick_check=1 http://www.loe.org/shows/segments.htm?programID=08-P13-00009&segmentID=5 Martha Farah, Director of the Center for Cognitive Neuroscience, University of Pennsylvania: �Stress is neurotoxic� it impacts the developing nervous system. In addition, there are factors like the greater incidence of maternal depression in poor families, and we know from studies of people at all income levels that maternal depression is actually very bad for child development. When moms are depressed they pay less attention to the kids. They engage with them less, they are less, you know, warm and involved, because they're depressed.� Sources: http://psych.upenn.edu/~mfarah/ http://www.ft.com/cms/s/0/62c45126-dc1f-11dc-bc82-0000779fd2ac.html?nclick_check=1 http://www.loe.org/shows/segments.htm?programID=08-P13-00009&segmentID=5

19. Conclusions Focus on children�s health Paradigm shift Focus on wellness and prevention Precautionary principle Interdisciplinary dialogue

20. References/Resources Rosen LD, Imus D: Environmental injustice: children's health disparities and the role of the environment. Explore (NY). 2007 Sep-Oct;3(5):524-8. CHE�s LDDI Scientific Consensus Statement on Environmental Agents Associated with Neurodevelopmental Disorders: www.healthandenvironment.org Integrative Pediatrics Council: www.integrativepeds.org, see for more web resources

21. Environmental Injustice:Focus on Pediatric Neurodevelopmental Disorders Lawrence D. Rosen, MD Chair, Integrative Pediatrics Council lrosen@integrativepeds.org