Developmental Pediatrics:
Children and the Environment
Leslie Rubin MD
Division of Developmental Pediatrics
Emory University
Leslie Rubin MD
Southeast PEHSU
Page 1
Children & The Environment
January 2001
What is meant by the term
“Developmental Disabilities”
?
Leslie Rubin MD
Southeast PEHSU
Page 2
Children & The Environment
January 2001
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.
Leslie Rubin MD
Southeast PEHSU
Page 3
Children & The Environment
January 2001
Familiar Terms
•
•
•
•
•
•
Leslie Rubin MD
Southeast PEHSU
Developmental Delay
Mental Retardation
Cerebral Palsy
Autism/PDD
Learning Disability
Attention Deficit Disorder
Page 4
Children & The Environment
January 2001
Familiar Terms
and Correlates
•
•
•
•
•
•
Leslie Rubin MD
Southeast PEHSU
Developmental Delay
Mental Retardation
Cerebral Palsy
Autism/PDD
Learning Disability
ADD
Page 5
motor
cognitive
motor
social
learning
focus
Children & The Environment
January 2001
Conceptualization of
Developmental Disabilities
Central Nervous
System
Motor
Cerebral
Palsy
Leslie Rubin MD
Southeast PEHSU
Cognitive
Mental
Retardation
Page 6
Social
Autism
Spectrum
Children & The Environment
January 2001
Conceptualization of
Developmental Disabilities
Prenatal
Perinatal
Postnatal
Central Nervous
System
Motor
Cerebral
Palsy
Leslie Rubin MD
Southeast PEHSU
Cognitive
Mental
Retardation
Page 7
Social
Autism
Spectrum
Children & The Environment
January 2001
Conceptualization of
Developmental Disabilities
Etiology:
Prenatal
Perinatal
Postnatal
Central Nervous
System
Function:
Motor
“Disability”:
Cerebral
Palsy
Leslie Rubin MD
Southeast PEHSU
Cognitive
Mental
Retardation
Page 8
Social
Autism
Spectrum
Children & The Environment
January 2001
Etiological Paradigms
• Prenatal
– Transplacental
• Perinatal
– Breathing & Skin
– Breast Milk
• Postnatal
– Breathing, Ingestion, Skin
– Visual
Leslie Rubin MD
Southeast PEHSU
Page 9
Children & The Environment
January 2001
Prenatal
•
•
•
•
•
Brain Development Takes Place
Factors Interfere with Brain Development
Neuronal Migration
Neuronal Connections
Neurochemistry
Leslie Rubin MD
Southeast PEHSU
Page 10
Children & The Environment
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
Southeast PEHSU
Page 11
Children & The Environment
January 2001
Perinatal Vulnerability
• Prematurity
• Congenital Syndrome
• Breast Milk
Leslie Rubin MD
Southeast PEHSU
Page 12
Children & The Environment
January 2001
Postnatal
•
•
•
•
Lead Toxicity
Mercury Toxicity
PCB Toxicity
Other Environmental Factors
Leslie Rubin MD
Southeast PEHSU
Page 13
Children & The Environment
January 2001
Environmental Factors
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•
•
•
chemicals and toxins
home environment
school environment
social environment
– TV, videos, video games, mass media
– lack of social cohesion
• political environment
Leslie Rubin MD
Southeast PEHSU
Page 14
Children & The Environment
January 2001
Cycle of Poverty
and Disability
Environment
Potential Outcomes
• neurodevelopmental disabilities
• child abuse
• foster care placement
• poverty
• poor community supports
• poor health services
• inadequate academic services
Self Worth
• despair
• substance abuse
• promiscuity
Risk Factors
• infant with increased needs
• medical needs
• developmental needs
• increased irritability
Pregnancy
• poor prenatal care
• tobacco, alcohol, and drug exposure
• risk of STDs/HIV
• mother under stress
• increased demands
• lack of supports
• substance abuse
Newborn Infant
• prematurity/LBW
• FAS
Leslie Rubin MD
Southeast PEHSU
Page 15
Children & The Environment
January 2001
Bell Curve
Leslie Rubin MD
Southeast PEHSU
Page 16
Children & The Environment
January 2001
Population Distribution
Leslie Rubin MD
Southeast PEHSU
Page 17
Children & The Environment
January 2001
Shift to the Left
Leslie Rubin MD
Southeast PEHSU
Page 18
Children & The Environment
January 2001
Lead
• Lead initially recognized as a multi-system
poison at levels exceeding 40 mg/dL
(anemia, abd cramps, seizures,
encephalopathy, renal colic)
• Only later recognized as a
neurodevelopmental toxin
Leslie Rubin MD
Southeast PEHSU
Page 19
Children & The Environment
January 2001
Lead and IQ
• Lead’s impact noticeable at BLL 10 mg/dL
• Taiwanese data suggest impact at BLL 5
mg/dL
• “Normal” BLL calculated to be <0.1 mg/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
Southeast PEHSU
Page 20
Children & The Environment
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
Southeast PEHSU
Page 21
Children & The Environment
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
Southeast PEHSU
Page 22
Children & The Environment
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
Southeast PEHSU
Page 23
Children & The Environment
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
Southeast PEHSU
Page 24
Children & The Environment
January 2001
PCB’s and Dioxins
PCB’s and dioxins share similar chemical
structures, are often found in fatty
tissues, and tend to accumulate in the
body over time.
Leslie Rubin MD
Southeast PEHSU
Page 25
Children & The Environment
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
Southeast PEHSU
Page 26
Children & The Environment
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
Southeast PEHSU
Page 27
Children & The Environment
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
Southeast PEHSU
Page 28
Children & The Environment
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
Southeast PEHSU
Page 29
Children & The Environment
January 2001
Chronic low-level exposure:
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Leslie Rubin MD
Southeast PEHSU
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]
Page 30
Children & The Environment
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
Southeast PEHSU
Page 31
Children & The Environment
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
Southeast PEHSU
Page 32
Children & The Environment
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
Southeast PEHSU
Page 33
Children & The Environment
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
Southeast PEHSU
Page 34
Children & The Environment
January 2001
Environmental Factors
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•
•
•
Chemicals and toxins
home environment
school environment
social environment
– TV, videos, video games, mass media
– lack of social cohesion
• political environment
Leslie Rubin MD
Southeast PEHSU
Page 35
Children & The Environment
January 2001
Diagnostic Issues
• What is the condition?
is it a disease or disorder?
•
•
•
•
Leslie Rubin MD
Southeast PEHSU
How do we diagnose it?
Who should make the diagnosis?
When should we refer?
To whom should we refer?
Page 36
Children & The Environment
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
Southeast PEHSU
Page 37
Children & The Environment
January 2001
The new guidelines:
• designed for primary care
physicians
• diagnosing ADHD
• in children age 6 to 12
Leslie Rubin MD
Southeast PEHSU
Page 38
Children & The Environment
January 2001
The new guidelines include the
following recommendations:
Evaluations should be initiated by the primary
care clinician for children who show signs of




Leslie Rubin MD
Southeast PEHSU
school difficulties,
academic underachievement,
troublesome relationships with
 teachers,
 family members and/or
 peers
other behavioral problems.
Page 39
Children & The Environment
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
Southeast PEHSU
Page 40
Children & The Environment
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
Southeast PEHSU
Page 41
Children & The Environment
January 2001
As many as one-third of children
diagnosed with ADHD also have
a co-existing condition.
Leslie Rubin MD
Southeast PEHSU
Page 42
Children & The Environment
January 2001
Diagnostic tests reviewed and
considered not effective.
lead screening
 tests for resistance to thyroid hormone
 brain image studies

Leslie Rubin MD
Southeast PEHSU
Page 43
Children & The Environment
January 2001
Differential Diagnosis
MEDICAL
• Tourette’s
syndrome
• tics
• sleep apnea
• absence seizures
• lead poisoning
• hyperthyroidism
• pin worms
Leslie Rubin MD
Southeast PEHSU
PSYCHIATRIC
• emotional distress
• PTSD
• disorder of mood or
anxiety
• oppositional defiant
disorder
• conduct disorder
Page 44
Children & The Environment
January 2001
Comorbidity
NEURODEVELOPMENTAL
• learning disorders
• language disorders
• cognitive impairment
• functionally significant
‘soft’ neurological
features
Leslie Rubin MD
Southeast PEHSU
EMOTIONALBEHAVIORAL
• lowered self esteem
• downward cycle
• school failure
• substance abuse
• antisocial behavior
• violence
Page 45
Children & The Environment
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
Southeast PEHSU
Page 46
Children & The Environment
January 2001
Learning Disabilities
• Impairment in abilities underlying
academic function
• Neuromotor incoordination
• Difficulties in orientation
• Impairment social adaptive
functioning
• Behavioral manifestations
Leslie Rubin MD
Southeast PEHSU
Page 47
Children & The Environment
January 2001
Management
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•
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•
•
•
Leslie Rubin MD
Southeast PEHSU
Support Groups
Environmental “Engineering”
Group Social Skills Training
Behavioral Management
Cognitive Behavioral Therapy
Traditional Psychotherapy
Page 48
Children & The Environment
January 2001
Management
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•
•
•
Educational Awareness
Classroom Placement
Classroom Positioning
Special Education
– Resource
– Self-contained
Leslie Rubin MD
Southeast PEHSU
Page 49
Children & The Environment
January 2001
Management
• Adjunctive Therapies
– Speech/Language
– Occupational Therapy
– Physical Therapy
• Pharmacotherapy
• Controversial Therapies
Leslie Rubin MD
Southeast PEHSU
Page 50
Children & The Environment
January 2001
Pharmacotherapy
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•
Leslie Rubin MD
Southeast PEHSU
Psychostimulants
Antidepressants
Antihypertensives
Anticonvulsants/Mood Stabilizers
Major Tranquilizers/Antipsychotics
Page 51
Children & The Environment
January 2001
Pharmacotherapy
Psychostimulants
• Ritalin
• Dexedrine
• Cylert
• Adderal
• Concerta
Leslie Rubin MD
Southeast PEHSU
Page 52
Children & The Environment
January 2001
Pharmacotherapy
Antidepressants
• Tricyclics - Tofranil, Norpramin, Elavil,
Pamelor
• SSRI’s - Prozac, Luvox, Paxil, Zoloft
• Wellbutrin
Leslie Rubin MD
Southeast PEHSU
Page 53
Children & The Environment
January 2001
Pharmacotherapy
Antihypertensives (alpha adrenergic agonists)
• Inderal
• Catapres
• Tenex
Leslie Rubin MD
Southeast PEHSU
Page 54
Children & The Environment
January 2001
Pharmacotherapy
Anticonvulsants/Mood Stabilizers
• Tegretol
• Depakene
• Lithium
Leslie Rubin MD
Southeast PEHSU
Page 55
Children & The Environment
January 2001
Pharmacotherapy
Major Tranquilizers/Antipsychotics
• Risperdal
• Mellaril
• Haldol
• Thorazine
Leslie Rubin MD
Southeast PEHSU
Page 56
Children & The Environment
January 2001
Prevalence
• Is it increasing?
• What are the postulated factors?
–
–
–
–
Family
School
Society
TV
• Is it Genetic?
Leslie Rubin MD
Southeast PEHSU
Page 57
Children & The Environment
January 2001
The Autism Spectrum Disorders
A Review
Leslie Rubin MD
Southeast PEHSU
Page 58
Children & The Environment
January 2001
A Brief Historic Review
•
•
•
•
•
Leslie Rubin MD
Southeast PEHSU
Childhood Psychosis
‘Psychoanalytic’ Theory
“Autism”
Recognition of Variations
Neuropathological Findings
Page 59
Children & The Environment
January 2001
Autism Spectrum Disorders
Clinical Varieties
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•
•
•
•
‘Classic’ Autism
Pervasive Developmental Disorder (PDD)
Asperger’s Syndrome
Rett’s Syndrome
“Others”
Leslie Rubin MD
Southeast PEHSU
Page 60
Children & The Environment
January 2001
Cardinal Clinical Features
• Delay in Speech Development
• Limited Social Interaction
• Unusual Stereotypic Behavior Patterns
Leslie Rubin MD
Southeast PEHSU
Page 61
Children & The Environment
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
Southeast PEHSU
Page 62
Children & The Environment
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
Southeast PEHSU
Page 63
Children & The Environment
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
Southeast PEHSU
Page 64
Children & The Environment
January 2001
IQ
Function
Bi-Dimensional
Developmental Theory
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 65
Children & The Environment
January 2001
IQ
Function
Bi-Dimensional
Developmental Theory
At Diagnosis
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 66
Children & The Environment
January 2001
Bi-Dimensional
Developmental Theory
IQ
Function
Desired Outcome
Developmental Progress with
Appropriate Intervention
Point of Diagnosis
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 67
Children & The Environment
January 2001
IQ
Function
Bi-Dimensional
Developmental Theory
Autism ?
Autism ?
Autism ?
Autism ?
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 68
Children & The Environment
January 2001
Bi-Dimensional
Developmental Theory
IQ
Function
Asperger’s ?
Asperger’s
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 69
Children & The Environment
January 2001
Bi-Dimensional
Developmental Theory
IQ
Function
PDD ?
PDD ?
PDD ?
PDD?
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 70
Children & The Environment
January 2001
IQ
Function
Bi-Dimensional
Developmental Theory
Rett ?
Rett ?
Rett ?
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 71
Children & The Environment
January 2001
Bi-Dimensional
Developmental Theory
IQ
Function
Fragile X ?
Other ?
Other ?
Other?
Down Syndrome ?
Other ?
Other ?
Function
Autistic Features
Leslie Rubin MD
Southeast PEHSU
Page 72
Children & The Environment
January 2001
Bi-Dimensional
Developmental Theory
IQ
Function
Asperger’s ?
Autism ?
PDD ?
Autism ?
Other ?
Rett ?
Leslie Rubin MD
Southeast PEHSU
Function
Autistic Features
Page 73
Children & The Environment
January 2001
Summary
• Evolving Knowledge and Understanding
• Importance of Increased Awareness
• Importance of Early Detection
• Importance of Accurate Diagnosis
• Importance of Optimal Intervention
Leslie Rubin MD
Southeast PEHSU
Page 74
Children & The Environment
January 2001