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

Leslie Rubin MD Children & The EnvironmentSoutheast PEHSU January 2001

Developmental Pediatrics:Children and the Environment

Leslie Rubin MDDivision of Developmental Pediatrics

Emory University


What is meant by the term“Developmental Disabilities”

?


.........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


Familiar Terms

• Developmental Delay

• Mental Retardation

• Cerebral Palsy

• Autism/PDD

• Learning Disability

• Attention Deficit Disorder


Familiar Termsand Correlates

• Developmental Delay motor

• Mental Retardation cognitive

• Cerebral Palsy motor

• Autism/PDD social

• Learning Disability learning

• ADD focus


Conceptualization of Developmental Disabilities

Central Nervous System

Motor Cognitive Social

Cerebral Palsy

Mental Retardation

AutismSpectrum




Prenatal Perinatal Postnatal


Cerebral Palsy

Mental Retardation

AutismSpectrum


“Disability”:

Function:

Etiology:


Prenatal Perinatal Postnatal


Cerebral Palsy

Mental Retardation

AutismSpectrum



Etiological Paradigms

• Prenatal – Transplacental

• Perinatal – Breathing & Skin– Breast Milk

• Postnatal – Breathing, Ingestion, Skin – Visual


Prenatal

• Brain Development Takes Place

• Factors Interfere with Brain Development

• Neuronal Migration

• Neuronal Connections

• Neurochemistry


Fetal Alcohol Syndrome(FAS)

Maternal Ingestion of Alcohol During Pregnancy

Effects on Fetus–Neurological Consequences

•Motor & Cognitive Performance•Behavior

Home Environment


Perinatal Vulnerability

• Prematurity

• Congenital Syndrome

• Breast Milk


Postnatal

• Lead Toxicity

• Mercury Toxicity

• PCB Toxicity

• Other Environmental Factors


Environmental Factors

• chemicals and toxins

• home environment

• school environment

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

• political environment


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


Bell Curve


Population Distribution


Shift to the Left


• 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


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


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.


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.


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.


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.


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


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).


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


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.


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


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]


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).


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


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.


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


Environmental Factors

• Chemicals and toxins

• home environment

• school environment

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

• political environment


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?


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.


The new guidelines:

• designed for primary care physicians

• diagnosing ADHD

• in children age 6 to 12


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.


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.


The assessment of ADHD should include:

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


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

a co-existing condition.


Diagnostic tests reviewed and considered not effective.

lead screening tests for resistance to thyroid hormone brain image studies


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


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


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”


Learning Disabilities

• Impairment in abilities underlying academic function

• Neuromotor incoordination

• Difficulties in orientation

• Impairment social adaptive functioning

• Behavioral manifestations


Management

• Support Groups

• Environmental “Engineering”

• Group Social Skills Training

• Behavioral Management

• Cognitive Behavioral Therapy

• Traditional Psychotherapy


Management

• Educational Awareness

• Classroom Placement

• Classroom Positioning

• Special Education– Resource– Self-contained


Management

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

• Pharmacotherapy

• Controversial Therapies


Pharmacotherapy

• Psychostimulants

• Antidepressants

• Antihypertensives

• Anticonvulsants/Mood Stabilizers

• Major Tranquilizers/Antipsychotics


Pharmacotherapy

Psychostimulants

• Ritalin

• Dexedrine

• Cylert

• Adderal

• Concerta


Pharmacotherapy

Antidepressants• Tricyclics - Tofranil, Norpramin, Elavil,

Pamelor

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

• Wellbutrin


Pharmacotherapy

Antihypertensives (alpha adrenergic agonists)

• Inderal

• Catapres

• Tenex


Pharmacotherapy

Anticonvulsants/Mood Stabilizers

• Tegretol

• Depakene

• Lithium


Pharmacotherapy

Major Tranquilizers/Antipsychotics

• Risperdal

• Mellaril

• Haldol

• Thorazine


Prevalence

• Is it increasing?

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

• Is it Genetic?


The Autism Spectrum Disorders

A Review


A Brief Historic Review

• Childhood Psychosis

• ‘Psychoanalytic’ Theory

• “Autism”

• Recognition of Variations

• Neuropathological Findings


Autism Spectrum DisordersClinical Varieties

• ‘Classic’ Autism

• Pervasive Developmental Disorder (PDD)

• Asperger’s Syndrome

• Rett’s Syndrome

• “Others”


Cardinal Clinical Features

• Delay in Speech Development

• Limited Social Interaction

• Unusual Stereotypic Behavior Patterns



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



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



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


Fun

ctio

n

Function

IQ

Autistic Features

Bi-DimensionalDevelopmental Theory


Fun

ctio

n

Function

IQ

Autistic Features


At Diagnosis


Fun

ctio

n

Function

IQ

Autistic Features


Developmental Progress withAppropriate Intervention

Desired Outcome

Point of Diagnosis


Fun

ctio

n

Function

IQ

Autistic Features


Autism ?

Autism ?

Autism ?

Autism ?


Fun

ctio

n

Function

IQ

Autistic Features


Asperger’s ?

Asperger’s


Fun

ctio

n

Function

IQ

Autistic Features


PDD ?

PDD ?

PDD?

PDD ?


Fun

ctio

n

Function

IQ

Autistic Features


Rett ?

Rett ?

Rett ?


Fun

ctio

n

Function

IQ

Autistic Features


Fragile X ?

Other ?

Other ?

Down Syndrome ?

Other ?

Other ?

Other?


Fun

ctio

n

Function

IQ

Autistic Features


Asperger’s ?

PDD ?

Rett ?

Autism ?

Autism ?

Other ?


Summary

• Evolving Knowledge and Understanding

• Importance of Increased Awareness

• Importance of Early Detection

• Importance of Accurate Diagnosis

• Importance of Optimal Intervention

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

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