leslie rubin mdpage 1 children & the environment southeast pehsu january 2001 developmental...

Leslie Rubin MD Page 1 Children & The EnvironmentSoutheast PEHSU January 2001

Developmental Pediatrics:Children and the Environment

Leslie Rubin MDDivision of Developmental Pediatrics

Emory University

Leslie Rubin MD Page 2 Children & The EnvironmentSoutheast PEHSU January 2001

What is meant by the term“Developmental Disabilities”

?

Leslie Rubin MD Page 3 Children & The EnvironmentSoutheast PEHSU January 2001

.........are conditions that have • origins in early life• are identified by delays or significant differences • in an infant or child’s development, • involve function across one or more domains, • require identification, intervention, and support, • in order to assure optimal function • of the individual and family in the community.

Developmental Disabilities

Leslie Rubin MD Page 4 Children & The EnvironmentSoutheast PEHSU January 2001

Familiar Terms

• Developmental Delay

• Mental Retardation

• Cerebral Palsy

• Autism/PDD

• Learning Disability

• Attention Deficit Disorder

Leslie Rubin MD Page 5 Children & The EnvironmentSoutheast PEHSU January 2001

Familiar Termsand Correlates

• Developmental Delay motor

• Mental Retardation cognitive

• Cerebral Palsy motor

• Autism/PDD social

• Learning Disability learning

• ADD focus

Leslie Rubin MD Page 6 Children & The EnvironmentSoutheast PEHSU January 2001

Conceptualization of Developmental Disabilities

Central Nervous System

Motor Cognitive Social

Cerebral Palsy

Mental Retardation

AutismSpectrum

Leslie Rubin MD Page 7 Children & The EnvironmentSoutheast PEHSU January 2001

Conceptualization of Developmental Disabilities

Central Nervous System

Prenatal Perinatal Postnatal

Motor Cognitive Social

Cerebral Palsy

Mental Retardation

AutismSpectrum

Leslie Rubin MD Page 8 Children & The EnvironmentSoutheast PEHSU January 2001

“Disability”:

Function:

Etiology:

Central Nervous System

Prenatal Perinatal Postnatal

Motor Cognitive Social

Cerebral Palsy

Mental Retardation

AutismSpectrum

Conceptualization of Developmental Disabilities

Leslie Rubin MD Page 9 Children & The EnvironmentSoutheast PEHSU January 2001

Etiological Paradigms

• Prenatal – Transplacental

• Perinatal – Breathing & Skin– Breast Milk

• Postnatal – Breathing, Ingestion, Skin – Visual

Leslie Rubin MD Page 10 Children & The EnvironmentSoutheast PEHSU January 2001

Prenatal

• Brain Development Takes Place

• Factors Interfere with Brain Development

• Neuronal Migration

• Neuronal Connections

• Neurochemistry

Leslie Rubin MD Page 11 Children & The EnvironmentSoutheast PEHSU January 2001

Fetal Alcohol Syndrome(FAS)

Maternal Ingestion of Alcohol During Pregnancy

Effects on Fetus–Neurological Consequences

•Motor & Cognitive Performance•Behavior

Home Environment

Leslie Rubin MD Page 12 Children & The EnvironmentSoutheast PEHSU January 2001

Perinatal Vulnerability

• Prematurity

• Congenital Syndrome

• Breast Milk

Leslie Rubin MD Page 13 Children & The EnvironmentSoutheast PEHSU January 2001

Postnatal

• Lead Toxicity

• Mercury Toxicity

• PCB Toxicity

• Other Environmental Factors

Leslie Rubin MD Page 14 Children & The EnvironmentSoutheast PEHSU January 2001

Environmental Factors

• chemicals and toxins

• home environment

• school environment

• social environment– TV, videos, video games, mass media– lack of social cohesion

• political environment

Leslie Rubin MD Page 15 Children & The EnvironmentSoutheast PEHSU January 2001

Cycle of Poverty and Disability

Self Worth• despair• substance abuse• promiscuity

Pregnancy• poor prenatal care • tobacco, alcohol, and drug exposure• risk of STDs/HIV

Newborn Infant• prematurity/LBW• FAS

Risk Factors• infant with increased needs

• medical needs• developmental needs• increased irritability

• mother under stress• increased demands • lack of supports• substance abuse

Potential Outcomes• neurodevelopmental disabilities• child abuse• foster care placement

Environment• poverty• poor community supports• poor health services• inadequate academic services

Leslie Rubin MD Page 16 Children & The EnvironmentSoutheast PEHSU January 2001

Bell Curve

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Population Distribution

Leslie Rubin MD Page 18 Children & The EnvironmentSoutheast PEHSU January 2001

Shift to the Left

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• Lead initially recognized as a multi-system poison at levels exceeding 40 g/dL (anemia, abd cramps, seizures, encephalopathy, renal colic)

• Only later recognized as a neurodevelopmental toxin

Lead

Leslie Rubin MD Page 20 Children & The EnvironmentSoutheast PEHSU January 2001

Lead and IQ

• Lead’s impact noticeable at BLL 10 g/dL

• Taiwanese data suggest impact at BLL 5 g/dL

• “Normal” BLL calculated to be <0.1 g/dL

• IQ seems to display “catch-up” to the expected norm in the child whose lead is mitigated and who is in a socially advantaged setting

Leslie Rubin MD Page 21 Children & The EnvironmentSoutheast PEHSU January 2001

Lead and behavior

• High lead children recognized to be more aggressive, more hyperactive than low lead children

• Behavior does NOT regress toward the expected over time, even in a socially advantaged setting

Mendelsohn AL et al. Pediatrics 1998; 101:e10-e17.

Burns JM et al. Am J Epidemiol 1999; 149:740-749.

Leslie Rubin MD Page 22 Children & The EnvironmentSoutheast PEHSU January 2001

Polychlorinated Biphenyls PCB’s?

• members of a chemical family that were formerly used in industry as lubricants, coatings, and insulation material for electrical equipment like transformers and capacitors

• tend to persist for long periods in the environment and had negative effects on wildlife. Thus, they were banned from use in 1977.

Leslie Rubin MD Page 23 Children & The EnvironmentSoutheast PEHSU January 2001

How can we be exposed to PCB’s ?

As a result of industrialization, small amounts of PCB’s are present in almost all outside air,

inside air, water, soil, and plants.

Leslie Rubin MD Page 24 Children & The EnvironmentSoutheast PEHSU January 2001

Sources of Exposure

Children playing in soils near certain hazardous waste sites may be exposed to

relatively high levels. This may occur from eating the soil or by absorption

across the skin.

Leslie Rubin MD Page 25 Children & The EnvironmentSoutheast PEHSU January 2001

PCB’s and dioxins share similar chemical structures, are often found in fatty

tissues, and tend to accumulate in the body over time.

PCB’s and Dioxins

Leslie Rubin MD Page 26 Children & The EnvironmentSoutheast PEHSU January 2001

Sources of PCB’s

Diet –

An important route of environmental PCB exposure is through the diet, especially milk (breast and dairy), fish, and other meats.

PCB’s tend to accumulate in the body, which is concerning considering that nursing infants may be exposed to relatively high PCB levels in breast milk (high fat content).

Leslie Rubin MD Page 27 Children & The EnvironmentSoutheast PEHSU January 2001

Possible sources of exposure include

Air –

xposure can occur in outdoor air close to certain hazardous waste facilities

Increased exposure to PCB’s may occur through breathing indoor air in buildings that have electrical appliances that use PCB’s

Leslie Rubin MD Page 28 Children & The EnvironmentSoutheast PEHSU January 2001

What are the health effects of PCB’s?

In the late 1960’s and early 1970’s, there were

two large-scale episodes of exposure to PCB contaminated rice oil in Japan and Taiwan.

This gave us insight into the health related problems.

Leslie Rubin MD Page 29 Children & The EnvironmentSoutheast PEHSU January 2001

Acute high-level exposure:irritation of the nose, throat, and lungs

various forms of skin rashes and acne (chloracne)

darkening of skin color

general weakness

impaired immune responses

increased rates of abortions, birth defects, mental retardation, facial abnormalities, and behavioral problems among children born to exposed mothers

Leslie Rubin MD Page 30 Children & The EnvironmentSoutheast PEHSU January 2001

Chronic low-level exposure:

decreased birth weight [3]

smaller head size [1][2][7]

increased rate of abortions [2][6]

problems with memory [2][8][9]

permanent learning disabilities [2][8][9]

problems with thyroid function [10][11]

problems with immune function [12]

Leslie Rubin MD Page 31 Children & The EnvironmentSoutheast PEHSU January 2001

Press Release AAP RELEASES

NEW GUIDELINES FOR DIAGNOSIS OF ADHD

News release of a policy published in the May issue of Pediatrics, the peer-reviewed Journal of the American Academy of Pediatrics (AAP).

For Release: May 1, 2000, 5:00 p.m. (ET) CHICAGO - The American Academy of Pediatrics (AAP) released new recommendations today for the assessment of school-age children with attention-deficit/hyperactivity disorder (ADHD).

Leslie Rubin MD Page 32 Children & The EnvironmentSoutheast PEHSU January 2001

Research in various community and practice settings shows

that…. between 4 and 12 percent of all

school age children may have ADHD, making it the most common childhood neurobehavioral disorder.

© 2000 - American Academy of Pediatrics

Leslie Rubin MD Page 33 Children & The EnvironmentSoutheast PEHSU January 2001

Research in various community and practice settings shows

that…. Children with ADHD may experience

significant functional problems such as: school difficulties, academic underachievement, troublesome relationships with family

members and peers, and behavioral problems.

Leslie Rubin MD Page 34 Children & The EnvironmentSoutheast PEHSU January 2001

In recent years, there has been growing interest in ADHD as well as

concerns about possible overdiagnosis

In surveys among pediatricians and family physicians across the country, wide variations were found in diagnostic criteria and treatment methods for ADHD.

© 2000 - American Academy of Pediatrics

Leslie Rubin MD Page 35 Children & The EnvironmentSoutheast PEHSU January 2001

Environmental Factors

• Chemicals and toxins

• home environment

• school environment

• social environment– TV, videos, video games, mass media– lack of social cohesion

• political environment

Leslie Rubin MD Page 36 Children & The EnvironmentSoutheast PEHSU January 2001

Diagnostic Issues

• What is the condition? is it a disease or disorder?

• How do we diagnose it?

• Who should make the diagnosis?

• When should we refer?

• To whom should we refer?

Leslie Rubin MD Page 37 Children & The EnvironmentSoutheast PEHSU January 2001

The new standardized AAP guidelines

• The guidelines were developed by a panel of medical, mental health and educational experts.

• The Agency for Healthcare Research and Quality provided significant research and background information for the new policy.

Leslie Rubin MD Page 38 Children & The EnvironmentSoutheast PEHSU January 2001

The new guidelines:

• designed for primary care physicians

• diagnosing ADHD

• in children age 6 to 12

Leslie Rubin MD Page 39 Children & The EnvironmentSoutheast PEHSU January 2001

The new guidelines include the following recommendations:

Evaluations should be initiated by the primary care clinician for children who show signs of

school difficulties, academic underachievement, troublesome relationships with

teachers, family members and/or peers

other behavioral problems.

Leslie Rubin MD Page 40 Children & The EnvironmentSoutheast PEHSU January 2001

The assessment of ADHD should include:

information obtained directly from parents or caregivers, as well as a classroom teacher or other school

professional, regarding: core symptoms of ADHD in various

settings

the age of onset, duration of symptoms and degree of functional impairment.

Leslie Rubin MD Page 41 Children & The EnvironmentSoutheast PEHSU January 2001

The assessment of ADHD should include:

assessment for co-existing conditions: learning and language problems, aggression, disruptive behavior, depression or anxiety.

Leslie Rubin MD Page 42 Children & The EnvironmentSoutheast PEHSU January 2001

As many as one-third of children diagnosed with ADHD also have

a co-existing condition.

Leslie Rubin MD Page 43 Children & The EnvironmentSoutheast PEHSU January 2001

Diagnostic tests reviewed and considered not effective.

lead screening tests for resistance to thyroid hormone brain image studies

Leslie Rubin MD Page 44 Children & The EnvironmentSoutheast PEHSU January 2001

Differential Diagnosis

PSYCHIATRIC• emotional distress• PTSD• disorder of mood or

anxiety• oppositional defiant

disorder• conduct disorder

MEDICAL• Tourette’s syndrome• tics• sleep apnea• absence seizures• lead poisoning• hyperthyroidism• pin worms

Leslie Rubin MD Page 45 Children & The EnvironmentSoutheast PEHSU January 2001

Comorbidity

NEURO-DEVELOPMENTAL

• learning disorders• language disorders• cognitive impairment• functionally significant

‘soft’ neurological features

EMOTIONAL-BEHAVIORAL

• lowered self esteem• downward cycle• school failure• substance abuse• antisocial behavior• violence

Leslie Rubin MD Page 46 Children & The EnvironmentSoutheast PEHSU January 2001

Learning Disabilities:Federal Guidelines

a “disorder in one or more of the basic psychologic processes involved in understanding or in using language, spoken or written, which may manifest itself as an imperfect ability to listen, think, speak, read, write, spell or do mathematical calculations”

Leslie Rubin MD Page 47 Children & The EnvironmentSoutheast PEHSU January 2001

Learning Disabilities

• Impairment in abilities underlying academic function

• Neuromotor incoordination

• Difficulties in orientation

• Impairment social adaptive functioning

• Behavioral manifestations

Leslie Rubin MD Page 48 Children & The EnvironmentSoutheast PEHSU January 2001

Management

• Support Groups

• Environmental “Engineering”

• Group Social Skills Training

• Behavioral Management

• Cognitive Behavioral Therapy

• Traditional Psychotherapy

Leslie Rubin MD Page 49 Children & The EnvironmentSoutheast PEHSU January 2001

Management

• Educational Awareness

• Classroom Placement

• Classroom Positioning

• Special Education– Resource– Self-contained

Leslie Rubin MD Page 50 Children & The EnvironmentSoutheast PEHSU January 2001

Management

• Adjunctive Therapies– Speech/Language– Occupational Therapy– Physical Therapy

• Pharmacotherapy

• Controversial Therapies

Leslie Rubin MD Page 51 Children & The EnvironmentSoutheast PEHSU January 2001

Pharmacotherapy

• Psychostimulants

• Antidepressants

• Antihypertensives

• Anticonvulsants/Mood Stabilizers

• Major Tranquilizers/Antipsychotics

Leslie Rubin MD Page 52 Children & The EnvironmentSoutheast PEHSU January 2001

Pharmacotherapy

Psychostimulants

• Ritalin

• Dexedrine

• Cylert

• Adderal

• Concerta

Leslie Rubin MD Page 53 Children & The EnvironmentSoutheast PEHSU January 2001

Pharmacotherapy

Antidepressants• Tricyclics - Tofranil, Norpramin, Elavil,

Pamelor

• SSRI’s - Prozac, Luvox, Paxil, Zoloft

• Wellbutrin

Leslie Rubin MD Page 54 Children & The EnvironmentSoutheast PEHSU January 2001

Pharmacotherapy

Antihypertensives (alpha adrenergic agonists)

• Inderal

• Catapres

• Tenex

Leslie Rubin MD Page 55 Children & The EnvironmentSoutheast PEHSU January 2001

Pharmacotherapy

Anticonvulsants/Mood Stabilizers

• Tegretol

• Depakene

• Lithium

Leslie Rubin MD Page 56 Children & The EnvironmentSoutheast PEHSU January 2001

Pharmacotherapy

Major Tranquilizers/Antipsychotics

• Risperdal

• Mellaril

• Haldol

• Thorazine

Leslie Rubin MD Page 57 Children & The EnvironmentSoutheast PEHSU January 2001

Prevalence

• Is it increasing?

• What are the postulated factors?– Family– School– Society– TV

• Is it Genetic?

Leslie Rubin MD Page 58 Children & The EnvironmentSoutheast PEHSU January 2001

The Autism Spectrum Disorders

A Review

Leslie Rubin MD Page 59 Children & The EnvironmentSoutheast PEHSU January 2001

A Brief Historic Review

• Childhood Psychosis

• ‘Psychoanalytic’ Theory

• “Autism”

• Recognition of Variations

• Neuropathological Findings

Leslie Rubin MD Page 60 Children & The EnvironmentSoutheast PEHSU January 2001

Autism Spectrum DisordersClinical Varieties

• ‘Classic’ Autism

• Pervasive Developmental Disorder (PDD)

• Asperger’s Syndrome

• Rett’s Syndrome

• “Others”

Leslie Rubin MD Page 61 Children & The EnvironmentSoutheast PEHSU January 2001

Cardinal Clinical Features

• Delay in Speech Development

• Limited Social Interaction

• Unusual Stereotypic Behavior Patterns

Leslie Rubin MD Page 62 Children & The EnvironmentSoutheast PEHSU January 2001

Cardinal Clinical Features

Delay in Speech Development- May have normal motor development- May start to say some words- At about 18 months stops speaking- May start speaking again towards age 3yrs

Limited Social Interaction Unusual Stereotypic Behavior Patterns

Leslie Rubin MD Page 63 Children & The EnvironmentSoutheast PEHSU January 2001

Cardinal Clinical Features

Delay in Speech Development Limited Social Interaction

- Limited eye contact- Prefers to be by self and play by self- Anxious about new people and social situations- Reluctant to relate on terms other than own- Can be encouraged to engage

Unusual Stereotypic Behavior Patterns

Leslie Rubin MD Page 64 Children & The EnvironmentSoutheast PEHSU January 2001

Cardinal Clinical Features

Delay in Speech Development Limited Social Interaction Unusual Stereotypic Behavior Patterns

- Repetitive hand movements- Rocking body movements- Walking on toes- Patterns in activity- Play has predictable patterns

Leslie Rubin MD Page 65 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

Leslie Rubin MD Page 66 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

At Diagnosis

Leslie Rubin MD Page 67 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

Developmental Progress withAppropriate Intervention

Desired Outcome

Point of Diagnosis

Leslie Rubin MD Page 68 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

Autism ?

Autism ?

Autism ?

Autism ?

Leslie Rubin MD Page 69 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

Asperger’s ?

Asperger’s

Leslie Rubin MD Page 70 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

PDD ?

PDD ?

PDD?

PDD ?

Leslie Rubin MD Page 71 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

Rett ?

Rett ?

Rett ?

Leslie Rubin MD Page 72 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

Fragile X ?

Other ?

Other ?

Down Syndrome ?

Other ?

Other ?

Other?

Leslie Rubin MD Page 73 Children & The EnvironmentSoutheast PEHSU January 2001

Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory

Asperger’s ?

PDD ?

Rett ?

Autism ?

Autism ?

Other ?

Leslie Rubin MD Page 74 Children & The EnvironmentSoutheast PEHSU January 2001

Summary

• Evolving Knowledge and Understanding

• Importance of Increased Awareness

• Importance of Early Detection

• Importance of Accurate Diagnosis

• Importance of Optimal Intervention