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Elevated exposure to multiple trace metals can be neurotoxic even at relatively low levels. These findings are primarily evident from adult occupational studies as well as in children exposed prenatally or in early childhood. Less research has focused on the neurodevelopmental impacts of exposure to metals among school-aged children. We examined associations between exposure to a mixture of four metals (arsenic, cadmium, manganese, lead) measured in hair and markers of cognition, attention, and behavior among 222 6-12 year old children who participated in a 2009-2010 neurodevelopmental follow-up to the C8 Health Project. Using quantile-based g-computation we estimated the adjusted overall metal mixture effect ψ (95 % CI) as the change in outcome per decile increase in all metals in the mixture. Hair metal levels varied by metal, with cadmium being lowest (median 0.007, interquartile range (IQR) 0.013 μg/g) and lead the highest concentration (median 0.152, IQR 0.252 μg/g). Children's cognitive skills and development, attention/impulsivity, and behavior were all close to standardized population means. Each decile increase in all metals was associated with a Full Scale IQ reduction of 1.01 points (95 % confidence interval (CI) -1.88, -0.15) and Verbal IQ reduction of 1.11 points (95 % CI -1.97, -0.25), adjusted for child age, sex, secondhand smoke exposure, HOME score, maternal education, maternal IQ, and examiner. Maternal report of ADHD-like behaviors and executive functioning also showed adverse associations with the metal mixture. Our findings suggest that similar to exposure during prenatal and early childhood periods, recent exposure to metals during middle childhood is associated with adverse neurodevelopmental consequences. Middle childhood may also be a developmental window of susceptibility to the negative consequences of exposure to environmental neurotoxicants.

BACKGROUND: The association between adversity and psychopathology in adolescents and adults is characterized by equifinality. These associations, however, have not been assessed during early childhood when psychopathology first emerges. Defining adversity using both dimensional and cumulative risk approaches, we examined whether specific types of adversity are differentially associated with psychopathology in preschool-aged children. METHODS: Measures of threat, deprivation, and total adversities (i.e., cumulative risk) were calculated based on parent-reported information for 755 2- to 5-year old children recruited from pediatric primary care clinics. Logistic regression was used to estimate cross-sectional associations between type of adversity and anxiety, depression, ADHD, and behavioral disorder diagnoses. RESULTS: Threat and cumulative risk exhibited independent associations with psychopathology. Threat was strongly related to behavioral disorders. Cumulative risk was consistently related to all psychopathologies. CONCLUSIONS: Using mutually adjusted models, we identified differential associations between threat and psychopathology outcomes in preschool-aged children. This selectivity may reflect different pathways through which adversity increases risk for psychopathology during this developmentally important period. As has been observed at other ages, a cumulative risk approach also effectively identified the cumulative impact of all forms of adversity on most forms of psychopathology during early childhood.

BACKGROUND Disability among women of reproductive age is common; many of these women desire children and do not have impaired fertility. OBJECTIVES To examine the epidemiological literature on perinatal health outcomes among women with physical disabilities. DATA SOURCES We searched Medline and CINAHL for articles published January 2009-April 2020 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. STUDY SELECTION AND DATA EXTRACTION Eligible studies were observational, quantitative, and reported on physical disabilities in association with prenatal, perinatal, postpartum, and/or infant health outcomes. We included studies that grouped physical and non-physical disabilities, such as surveys that queried only about general daily life limitations. We excluded case reports, descriptive studies without comparison groups, and studies conducted in low- or middle-income countries. Data extraction was done using predefined data fields. SYNTHESIS All authors were involved in screening activities, data extraction, and/or quality assessment (rating and areas for bias). RESULTS A total of 2650 articles were evaluated, of which sixteen met inclusion criteria (8 cross-sectional studies and 8 retrospective cohort studies). Assessments of disability status and perinatal outcomes widely varied across studies. Studies were rated as poor (n = 8) or fair quality (n = 8). Findings suggested that women with physical disabilities were at risk of several adverse outcomes, including caesarean delivery, infections, preterm complications, and maternal post-delivery hospitalisations, while their infants may be at risk of low birthweight and small-for-gestational age. Women classified as having complex/severe disabilities were often observed to be at higher risk of adverse outcomes compared to women with less severe disabilities. CONCLUSIONS Research assessing how physical, functional, and medical restrictions influence health outcomes among women with physical disabilities, from preconception through postpartum, is limited. Longitudinal studies with comprehensive data collection that accurately identify women with physical disabilities are critical to understanding their reproductive health risks and outcomes.

To synthesize current knowledge of the impact of pediatric neuropsychological evaluations on child functioning, we conducted a systematic review of the literature on parents' overall satisfaction with their child's evaluation and perceptions of how helpful the evaluation was for understanding their child's abilities and how useful the evaluation was for providing actionable information to elicit change. Parent satisfaction is important in this context because studies on healthcare consumption indicate a substantial relationship between patient satisfaction with services and implementation of recommendations and follow-up care. We followed PRISMA guidelines to conduct a systematic review of the literature on parent perception of pediatric neuropsychological evaluations for children aged 3-21 years. Using a set of predefined search terms, we identified 1,163 abstracts across PubMed, PsycINFO, Cochrane Library, and Web of Science electronic databases and included 12 studies in our qualitative synthesis. In general, parents reported high levels of satisfaction with their child's evaluation. Feedback from the evaluation was helpful for understanding their child's pattern of strengths and weaknesses and included useful information for obtaining support. Although parents did report improvement in their child's functional participation in home, school, and community settings, they tended to rate the usefulness of the evaluation for eliciting change lower than their overall satisfaction with the evaluation or how helpful the evaluation was for understanding their child's abilities. Additional effort appears to be needed for pediatric neuropsychological evaluations recommendations to result in durable, meaningful change in child functioning.

Context Postpartum depression (PPD) is a serious psychiatric disorder. While causes remain poorly understood, perinatal sex hormone fluctuations are an important factor, and allopregnanolone in particular has emerged as a key determinant. Although synthetic environmental chemicals such as bisphenols and phthalates are known to affect sex hormones, no studies have measured allopregnanolone and the consequences of these hormonal changes on PPD have not been interrogated. Objective To investigate associations of repeated measures of urinary bisphenols and phthalates in early and midpregnancy with serum pregnenolone, progesterone, allopregnanolone, and pregnanolone concentrations in midpregnancy and PPD symptoms at 4 months postpartum. Methods Prospective cohort study of 139 pregnant women recruited between 2016 and 2018. Bisphenols and phthalates were measured in early and midpregnancy urine samples. Serum sex steroid hormone concentrations were measured in midpregnancy. PPD was assessed at 4 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multiple informant models were fit using generalized estimating equations. Serum levels of allopregnanolone, progesterone, pregnanolone, and pregnenolone were examined as log-transformed continuous variables. PPD symptoms were examined as continuous EPDS scores and dichotomously with scores ≥10 defined as PPD. Results Di-n-octyl phthalate (DnOP) and diisononyl phthalate (DiNP) metabolites were associated with reduced progesterone concentrations. Log-unit increases in ∑DnOP and ∑DiNP predicted 8.1% (95% CI –15.2%, –0.4%) and 7.7% (95% CI –13.3%, –1.7%) lower progesterone, respectively. ∑DnOP was associated with increased odds of PPD (odds ratio 1.48; 95% CI 1.04, 2.11). Conclusion Endocrine disrupting chemicals may influence hormonal shifts during pregnancy as well as contribute to PPD.

Background: There are significant racial and socioeconomic disparities in health outcomes for patients with type 1 diabetes (T1D) . COVID-also disproportionately affected racial/ethnic minority groups. Objective: We examined whether the pandemic differentially impacted patients with T1D who identified as minority (Hispanic, non-Hispanic Black, Asian) versus non-minority (non-Hispanic white) . Methods: We administered the COVID-Exposure and Family Impact Survey to adolescents with T1D seen at the NYU Pediatric Diabetes Center from May 2020 - May 2021 (n=165) . Patient characteristics were compared using chi-square tests and linear regression models. Results: Respondents (n=41) had a median age of 17 years (range 15-23, SD 2.2) . Most respondents identified as non-minority (58.5%) , female (53.7%) , and were privately insured (65.9%) . Those identifying as minority had higher distress scores (5.4 versus 3.9; p=.07) , less continuous glucose monitor use, and higher HbA1c levels compared to non-minority patients (p Conclusion: Adolescents with T1D who identified as minority race reported a greater impact of the COVID-pandemic on their physical and psychosocial functioning compared to their non-minority peers. Further study may identify how to mitigate these worse outcomes. Disclosure M.Goldberg: None. J.Ilkowitz: None. J.E.Gonzalez: None. C.R.Stein: None. M.Gallagher: None.

Background: Early research suggests during the COVID-19 pandemic there was an increase in new onset diabetes mellitus (DM) and greater severity at presentation. We examined pandemic related trends of new onset DM among patients at a pediatric diabetes center in New York, NY. Methods: We conducted a retrospective chart review of 168 youth 0-26 years old presenting with new onset DM from January 2019 to October 2021. We used chi-square statistics, t-tests, and ANOVAs to compare aspects of presentation by year of diagnosis, overall and type 2 DM (T2D) versus type 1 DM (T1D) . Results: The number of patients presenting with new onset DM increased throughout this time, with 43 in 2019, 57 in 2020, and 68 in 2021. This increase was primarily driven by an increase in T2D (8 in 2019, 16 in 2020, 27 in 2021) . Patients with T2D had higher mean BMI percentile at presentation compared to T1D (97.5 vs. 42.9; p Conclusions: In this population, the number of pediatric new onset DM increased during the COVID-19 pandemic. Cases of T2D increased by a greater degree than T1D which may explain the increased mean BMI percentile at diagnosis. There was no change in severity of DM presentation when examining multiple markers of severity. Further research is needed to understand if lifestyle changes during the pandemic may have impacted BMI and how this may relate to new onset pediatric DM, particularly T2D. Disclosure K. Citron: None. C. R. Stein: None. J. Ilkowitz: None. J. E. Gonzalez: None. V. Joseph: None. M. Gallagher: None.

This study examined product use among pregnant women and new mothers in New York City during the COVID-19 pandemic (July 2020–June 2021). Women reported use of personal care and household cleaning products within the previous month, changes in antibacterial product use, receipt of healthcare provider advice, and opinions on environmental chemicals (n = 320). On average, women used 15 personal care products and 7 household cleaning products. Non-Hispanic Black women used nearly two more personal care products; non-Hispanic Black women, those with a college degree, and essential workers used 1–3 more household cleaning products. Women who were Hispanic or reported their race and ethnicity as Other were two times more likely to use antibacterial personal care products. Non-Hispanic Black, Hispanic, and women who reported their race and ethnicity as Other were 1.5 times more likely to increase antibacterial product use during the pandemic. Nearly all women agreed that environmental chemicals pose health risks and are impossible to avoid, while less than one quarter received advice regarding product use. Product use is a modifiable source of chemical exposures. Results from this study suggest that women may have increased their product use during the pandemic. Healthcare providers may use the current focus on health hygiene to promote discussion and assessment of environmental chemical exposures with patients.

Female adults of reproductive age (18 to 44 years) with disabilities have higher rates of health-risk behaviors and chronic conditions compared with their counterparts without disabilities; however, there is limited examination of diet.Our aim was to examine associations of self-reported disability status with diet quality and diet-related factors.Cross-sectional data were from the National Health and Nutrition Examination Surveys, 2013-2018.Female adults aged 18 through 44 years were included. Disability was defined as serious difficulty hearing, seeing, concentrating, walking, dressing, and/or running errands due to physical, mental, or emotional conditions.The Healthy Eating Index-2015 assessed diet quality. Diet-related factors included self-rated diet healthfulness, meal characteristics, food security, and food assistance programs.Multivariable linear regression estimated differences in Healthy Eating Index-2015 scores for a given day and multivariable Poisson regression estimated adjusted prevalence ratios and 95% CI of diet-related factors by disability status.Of 3,579 female adults, 557 (16%) reported any disabilities, 207 (6%) of whom reported having 2 or more types of disabilities. Differences in mean Healthy Eating Index-2015 scores for a given day were one-third to one-half a point lower for fruits, total protein foods, and seafood and plant proteins among female adults with 2 or more types of disabilities compared with those without disabilities. Female adults with any disabilities were more likely to rate their diet as poor, have low food security, participate in food-assistance programs, and consume frozen foods or pizza, compared with those without disabilities (adjusted prevalence ratio ranged from 1.35 to 1.93); they were less likely to be the main food planner or preparer or shopper for their households.Some indicators of diet quality and diet-related factors differed between female adults with and without disabilities. Additional investigation of dietary intakes and behaviors, as well as access to and availability of healthy foods, among female adults with disabilities is necessary.

This study aimed to characterize suicide risk screening results for youth in pediatric ambulatory subspecialty clinics.The Ask Suicide-Screening Questions was administered to patients ages 9-24 years in 12 subspecialty clinics to assess suicide risk, determined by suicide ideation/behavior. The SAMSHA-HRSA standard framework for integrated health was used to categorize each clinic's level of behavioral health integration.6365 patients completed 7440 suicide risk screens; 6.2% of patients screened positive at their initial screen and 4.1% at subsequent annual screens. There was no dose-response pattern between increasing level of integration and decreasing likelihood of a positive suicide screen. Youth identifying as gender expansive were 3.1 times (95% CI [2.0, 4.9]) more likely to screen positive as compared to cisgender youth, adjusted for age, gender, race/ethnicity, screen type, year, and clinic integration level.Results surrounding disparities in suicide risk based on gender identity underscore the importance of further investigating how to optimally identify and manage high-risk, often understudied youth at suicide risk.

To synthesize current knowledge of the impact of pediatric neuropsychological evaluations on child functioning, we conducted a systematic review of the literature on parents' overall satisfaction with their child's evaluation and perceptions of how helpful the evaluation was for understanding their child's abilities and how useful the evaluation was for providing actionable information to elicit change. Parent satisfaction is important in this context because studies on healthcare consumption indicate a substantial relationship between patient satisfaction with services and implementation of recommendations and follow-up care. We followed PRISMA guidelines to conduct a systematic review of the literature on parent perception of pediatric neuropsychological evaluations for children aged 3-21 years. Using a set of predefined search terms, we identified 1,163 abstracts across PubMed, PsycINFO, Cochrane Library, and Web of Science electronic databases and included 12 studies in our qualitative synthesis. In general, parents reported high levels of satisfaction with their child's evaluation. Feedback from the evaluation was helpful for understanding their child's pattern of strengths and weaknesses and included useful information for obtaining support. Although parents did report improvement in their child's functional participation in home, school, and community settings, they tended to rate the usefulness of the evaluation for eliciting change lower than their overall satisfaction with the evaluation or how helpful the evaluation was for understanding their child's abilities. Additional effort appears to be needed for pediatric neuropsychological evaluations recommendations to result in durable, meaningful change in child functioning.

While youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates, general psychiatric settings are not designed to meet their unique needs. Previous evaluations of an ASD-Care Pathway (ASD-CP) on a general psychiatric unit revealed sustained reductions in crisis interventions (intramuscular medication use, holds/restraints; Cervantes et al. in J Autism Dev Disord 49(8):3173–3180, https://doi.org/10.1007/s10803-019-04029-6 , 2019; Kuriakose et al. in J Autism Dev Disord 48(12):4082–4089, https://doi.org/10.1007/s10803-018-3666-y , 2018). The current study investigated staff perceptions of the ASD-CP (N = 30), and examined rates of ASD-CP implementation fidelity in relation to patient outcomes (N = 28). Staff identified visual communication aids and reward strategies as most helpful. The number of days of reward identification early in the inpatient stay was associated with fewer crisis interventions later in a patient’s stay.

Decline in cognitive functioning among rescue and recovery workers who responded in the aftermath of the September 11, 2001, World Trade Center (WTC) attacks is of emerging interest. Responders are vulnerable to cognitive decline from exposure to airborne toxins present at the WTC site, as well as from WTC-related mental and physical health conditions. To better understand the relationship between occupational WTC exposure, mental health, physical health and subjective cognitive functioning, we examined the mediating role of health status in the association between exposure and subjective cognitive concerns in a multi-site, longitudinal investigation of the WTC General Responder cohort (n = 16,380 responders; n = 58,575 visits) for the period 2002–2015. Through latent class analyses, we identified a four-level marker of cognitive concerns based on information from a Self-Administered Mental Health Questionnaire. Using generalized linear mixed models with random intercepts, we observed that a higher intensity WTC exposure composite was associated with greater cognitive concerns, and that this association was operating almost entirely through mental health comorbidities, not physical health comorbidities. In fully adjusted models, the inclusion of probable depression, anxiety, PTSD and use of psychotropic medications attenuated the association between highest WTC exposure and greatest cognitive concerns. Physical health did not appear to be on the pathway between WTC exposure and cognitive concerns. Understanding the underlying sources of cognitive concerns may help identify vulnerable members of the General Responder cohort and potentially aid clinical decision-making, such as treatment choice and enhanced screening options. Earlier diagnosis and symptom treatment may help preserve functional independence.

Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.

Background The C8 Science Panel was composed of three epidemiologists charged with studying the possible health effects of PFOA in a highly exposed population in the mid-Ohio Valley. The Panel determined in 2012 there was a ‘probable link’ (i.e., more probable than not based on the weight of the available scientific evidence) between PFOA and high cholesterol, thyroid disease, kidney and testicular cancer, pregnancy-induced hypertension, and ulcerative colitis. Objective Here, former C8 Science Panel members and collaborators comment on the PFOA literature regarding thyroid disorders, cancer, immune and auto-immune disorders, liver disease, hypercholesterolemia, reproductive outcomes, neurotoxicity, and kidney disease. We also discuss developments regarding fate and transport, and pharmacokinetic models, and discuss causality assessment in cross-sectional associations among low-exposed populations. Discussion For cancer, the epidemiologic evidence remains supportive but not definitive for kidney and testicular cancers. There is consistent evidence of a positive association between PFOA and cholesterol, but no evidence of an association with heart disease. There is evidence for an association with ulcerative colitis, but not for other auto-immune diseases. There is good evidence that PFOA is associated with immune response, but uneven evidence for an association with infectious disease. The evidence for an association between PFOA and thyroid and kidney disease is suggestive but uneven. There is evidence of an association with liver enzymes, but not with liver disease. There is little evidence of an association with neurotoxicity. Suggested reductions in birthweight may be due to reverse causality and/or confounding. Fate and transport models and pharmacokinetic models remain central to estimating past exposure for new cohorts, but are difficult to develop without good historical data on emissions of PFOA into the environment. Conclusion Overall, the epidemiologic evidence remains limited. For a few outcomes there has been some replication of our earlier findings. More longitudinal research is needed in large populations with large exposure contrasts. Additional cross-sectional studies of low exposed populations may be less informative.

Background Multiple chronic health conditions have been associated with exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We assessed whether excess deaths occurred during 2003–2014 among persons directly exposed to 9/11, and examined associations of 9/11-related exposures with mortality risk. Materials and methods Deaths occurring in 2003–2014 among members of the World Trade Center Health Registry, a cohort of rescue/recovery workers and lower Manhattan community members who were exposed to 9/11, were identified via linkage to the National Death Index. Participants’ overall levels of 9/11-related exposure were categorized as high, intermediate, or low. We calculated standardized mortality ratios (SMR) using New York City reference rates from 2003 to 2012. Proportional hazards were used to assess associations of 9/11-related exposures with mortality, accounting for age, sex, race/ethnicity and other potential confounders. Results We identified 877 deaths among 29,280 rescue/recovery workers (3.0%) and 1694 deaths among 39,643 community members (4.3%) during 308,340 and 416,448 person-years of observation, respectively. The SMR for all causes of death was 0.69 [95% confidence interval (CI) 0.65–0.74] for rescue/recovery workers and 0.86 (95% CI 0.82–0.90) for community members. SMRs for diseases of the cardiovascular and respiratory systems were significantly lower than expected in both groups. SMRs for several other causes of death were significantly elevated, including suicide among rescue recovery workers (SMR 1.82, 95% CI 1.35–2.39), and brain malignancies (SMR 2.25, 95% CI 1.48–3.28) and non-Hodgkin's lymphoma (SMR 1.79, 95% CI 1.24–2.50) among community members. Compared to low exposure, both intermediate [adjusted hazard ratio (AHR) 1.36, 95% CI 1.10–1.67] and high (AHR 1.41, 95% CI 1.06–1.88) levels of 9/11-related exposure were significantly associated with all-cause mortality among rescue/recovery workers (p-value for trend 0.01). For community members, intermediate (AHR 1.13, 95% CI 1.01–1.27), but not high (AHR 1.14, 95% CI 0.94–1.39) exposure was significantly associated with all-cause mortality (p-value for trend 0.03). AHRs for associations of overall 9/11-related exposure with heart disease- and cancer-related mortality were similar in magnitude to those for all-cause mortality, but with 95% CIs crossing the null value. Conclusions Overall mortality was not elevated. Among specific causes of death that were significantly elevated, suicide among rescue/recovery workers is a plausible long-term consequence of 9/11 exposure, and is potentially preventable. Elevated mortality due to other causes, including non-Hodgkin's lymphoma and brain cancer, and small but statistically significant associations of 9/11-related exposures with all-cause mortality hazard warrant additional surveillance.

Background: Prior studies have found that rescue and recovery workers exposed to the 9/11 World Trade Center (WTC) disaster have evidence of increased persistent hearing and other ear-related problems. The potential association between WTC disaster exposures and post-9/11 persistent self-reported hearing problems or loss among non-rescue and recovery survivors has not been well studied. Methods: We used responses to the World Trade Center Health Registry (Registry) enrollment survey (2003&ndash, 2004) and first follow-up survey (2006&ndash, 2007) to model the association between exposure to the dust cloud and persistent hearing loss (n = 22,741). Results: The prevalence of post-9/11 persistent hearing loss among survivors was 2.2%. The adjusted odds ratio (aOR) of hearing loss for those who were in the dust cloud and unable to hear was 3.0 (95% CI: 2.2, 4.0). Survivors with persistent sinus problems, headaches, PTSD and chronic disease histories had an increased prevalence of reported hearing problems compared to those without symptoms or chronic problems. Conclusions: In a longitudinal study, we observed an association between WTC-related exposures and post-9/11 self-reported hearing loss among disaster survivors.

Objective To determine if World Trade Center (WTC) exposure is associated with hearing loss. Methods Logistic regression to evaluate the immediate impact of WTC exposure and parametric survival analysis to assess longitudinal outcomes. Results Those arriving on the morning of September 11, 2001 had elevated odds of low-frequency (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.04 to 1.47) and high-frequency (OR: 1.16; 95% CI: 1.02 to 1.31) hearing loss at their first post-September 11, 2001 examination. Longitudinally, participants arriving before September 13, 2001 and spending more than or equal to 6 months at the WTC-site had greater risk of hearing loss in the low frequencies (risk ratio [RR]: 1.31; 95% CI: 1.05 to 1.60) and high frequencies (RR: 1.37; 95% CI: 1.22 to 1.54). By 2016, 3194 (37%) had abnormal hearing sensitivity in either ear and 1751 (20%) in both ears. Conclusions More heavily WTC-exposed workers were at increased risk of hearing loss, and group differences persisted for at least 15 years. Those with abnormal hearing sensitivity may benefit from interventions such as hearing aids and other rehabilitation.

Residential mobility is hypothesized to impact health through changes to the built environment and disruptions in social networks, and may vary by neighborhood deprivation exposure. However, there are few longitudinal investigations of residential mobility in relation to health outcomes. This study examined enrollees from the World Trade Center Health Registry, a longitudinal cohort of first responders and community members in lower Manhattan on September 11, 2001. Enrollees who completed ≥2 health surveys between 2004 and 2016 and did not have diabetes (N = 44,089) or hypertension (N = 35,065) at baseline (i.e., 2004) were included. Using geocoded annual home addresses, residential mobility was examined using two indicators: moving frequency and displacement. Moving frequency was defined as the number of times someone was recorded as living in a different neighborhood; displacement as any moving to a more disadvantaged neighborhood. We fit adjusted Cox proportional hazards models with time-dependent exposures (moving frequency and displacement) and covariates to evaluate associations with incident diabetes and hypertension. From 2004 to 2016, the majority of enrollees never moved (54.5%); 6.5% moved ≥3 times. Those who moved ≥3 times had a similar hazard of diabetes (hazard ratio (HR) = 0.78; 95% Confidence Interval (CI): 0.40, 1.53) and hypertension (HR = 0.99; 95% CI: 0.68, 1.43) compared with those who never moved. Similarly, displacement was not associated with diabetes or hypertension. Residential mobility was not associated with diabetes or hypertension among a cohort of primarily urban-dwelling adults.

Background Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks. Methods We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003–2004) and follow-up (2015–16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey. Results In 2015–16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year. Conclusions Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015–2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

Perfluoroalkyl substances (PFAS) were shown to be immunotoxic in laboratory animals. There is some epidemiological evidence that PFAS exposure is inversely associated with vaccine-induced antibody concentration. We examined immune response to vaccination with FluMist intranasal live attenuated influenza vaccine in relation to four PFAS (perfluorooctanoate, perfluorononanoate, perfluorooctane sulfonate, perfluorohexane sulfonate) serum concentrations among 78 healthy adults vaccinated during the 2010 – 2011 influenza season. We measured anti-A H1N1 antibody response and cytokine and chemokine concentrations in serum pre-vaccination, 3 days post-vaccination, and 30 days post-vaccination. We measured cytokine, chemokine, and mucosal IgA concentration in nasal secretions 3 days post-vaccination and 30 days post-vaccination. Adults with higher PFAS concentrations were more likely to seroconvert after FluMist vaccination as compared to adults with lower PFAS concentrations. The associations, however, were imprecise and few participants seroconverted as measured either by hemagglutination inhibition (9%) or immunohistochemical staining (25%). We observed no readily discernable or consistent pattern between PFAS concentration and baseline cytokine, chemokine, or mucosal IgA concentration, or between PFAS concentration and change in these immune markers between baseline and FluMist-response states. The resuts of this study do not support a reduced immune response to FluMist vaccination among healthy adults in relation to serum PFAS concentration. Given the study’s many limitations, however, it does not rule out impaired vaccine response to other vaccines or vaccine components in either children or adults.

Background Rescue and recovery workers responding to the 2001 collapse of the World Trade Center (WTC) sustained exposures to toxic chemicals and have elevated rates of multiple morbidities. Methods Using data from the World Trade Center Health Program and the National Death Index for 2002–2011, we examined standardized mortality ratios (SMR) and proportional cancer mortality ratios (PCMR) with indirect standardization for age, sex, race, and calendar year to the U.S. general population, as well as associations between WTC-related environmental exposures and all-cause mortality. Results We identified 330 deaths among 28,918 responders (SMR 0.43, 95%CI 0.39–0.48). No cause-specific SMRs were meaningfully elevated. PCMRs were elevated for neoplasms of lymphatic and hematopoietic tissue (PCMR 1.76, 95%CI 1.06–2.75). Mortality hazard ratios showed no linear trend with exposure. Conclusions Consistent with a healthy worker effect, all-cause mortality among responders was not elevated. There was no clear association between intensity and duration of exposure and mortality. Surveillance is needed to monitor the proportionally higher cancer mortality attributed to lymphatic/hematopoietic neoplasms. Am. J. Ind. Med. 59:87–95, 2016. © 2016 Wiley Periodicals, Inc.

Internal and international migration impacts family structure, parent–child relationships, and child care arrangements for the world’s ∼1 billion migrants.1 When parents migrate without their children, this experience of prolonged separation has profound repercussions on children’s development and well-being. Because international migration disrupts family systems globally, internal migration, such as rural-to-urban migration in low- and middle-income countries, also has massive impacts. In China alone, 61 million rural children are living apart from their parents who have migrated to urban areas.2 These so-called “left-behind children” comprise 34% of all rural children and 22% of the total child population in China.2 The well-being of children who are affected by parental migration has raised concerns worldwide. Although labor-related migration tends to improve a family’s socioeconomic circumstances, a prolonged separation from migrant parents can place children at an increased risk for psychosocial disorders.3 Even reunification with parents may lead to additional distress because of an abrupt restructuring of family dynamics.4,5 Despite the many clinical implications of parental migration and family separation, little information is available to help clinicians understand how parental migration may affect mental and behavioral development in children. Migrant parents often leave their children behind in the pursuit of employment even in Asian cultures, in which family connection is emphasized as the major source of identity and protection. Factors that prevent migrant parents from bringing their children along include residence permit policies, a high cost of living, and a lack of access to child care and education. … Address correspondence to Chenyue Zhao, PhD, Department of Child and Adolescent Psychiatry, School of Medicine, New York University, 1 Park Ave, 7th Floor, New York, NY 10016. E-mail: chenyue.zhao{at}nyumc.org

Biomarkers of environmental metal exposure in children are important for elucidating exposure and health risk. While exposure biomarkers for As, Cd, and Pb are relatively well defined, there are not yet well-validated biomarkers of Mn exposure. Here, we measured hair Mn, Pb, Cd, and As levels in children from the Mid-Ohio Valley to determine within and between-subject predictors of hair metal levels. Occipital scalp hair was collected in 2009–2010 from 222 children aged 6–12 years (169 female, 53 male) participating in a study of chemical exposure and neurodevelopment in an industrial region of the Mid-Ohio Valley. Hair samples from females were divided into three two centimeter segments, while males provided a single segment. Hair was cleaned and processed in a trace metal clean laboratory, and analyzed for As, Cd, Mn, and Pb by magnetic sector inductively coupled plasma mass spectrometry. Hair Mn and Pb levels were comparable (median 0.11 and 0.15 µg/g, respectively) and were ~10-fold higher than hair Cd and As levels (0.007 and 0.018 µg/g, respectively). Hair metal levels were higher in males compared to females, and varied by ~100–1000-fold between all subjects, and substantially less (10-fold lower than levels reported in other studies in children, most likely because of more rigorous hair cleaning methodology used in the present study, leading to lower levels of unresolved exogenous metal contamination of hair.

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are immunotoxic in laboratory studies. Human studies of immune effects are inconsistent. Using the US National Health and Nutrition Examination Survey (NHANES), we examined PFAS serum concentration and indicators of prevalent immune function among 12–19-y-old children. In this cross-sectional study, we examined PFAS serum concentration in relation to measles, mumps, and rubella antibody concentrations in NHANES 1999–2000 and 2003–2004 (n = 1,191) and to allergic conditions and allergic sensitization in NHANES 2005–2006 (n = 640). In adjusted, survey-weighted models, a doubling of perfluorooctane sulfonate (PFOS) concentration among seropositive children was associated with a 13.3% (95% confidence interval (CI): −19.9, −6.2) decrease in rubella antibody concentration and a 5.9% decrease in mumps antibody concentration (95% CI: −9.9, −1.6). We observed no adverse association between exposure and current allergic conditions, including asthma. Children with higher PFOS concentration were less likely to be sensitized to any allergen (odds ratio (OR): 0.74; 95% CI: 0.58, 0.95). Increased exposure to several PFAS was associated with lower levels to mumps and rubella antibody concentrations, especially among seropositive individuals. These lower antibody concentrations may indicate a less robust response to vaccination or greater waning of vaccine-derived immunity over time.

To examine the association between 9/11-related exposures and self-reported hearing problems among 16,579 rescue/recovery workers in the World Trade Center (WTC) Health Registry.Using Registry Waves 1 (2003 to 2004) and 2 (2006 to 2007), we modeled the association between two metrics of 9/11-related exposures and hearing difficulties.The prevalence of incident, persistent hearing problems was 4.4%. In a fully adjusted model, workers with higher environmental hazards scores were twice as likely (interquartile range OR 2.1; 95% confidence interval [CI] 1.8, 2.5) to report hearing problems. Based on the same fully adjusted model, workers unable to hear in the dust cloud were 2.3 (95% CI 1.8, 3.0) times more likely to report hearing problems as compared with workers not in the dust cloud.We observed a consistent association between WTC-related exposures and self-reported hearing problems among rescue/recovery workers.

Perfluorooctanoate (PFOA) is a perfluorinated compound (PFC) that has been widely used in numerous consumer products since the 1950s.1–3 Human exposure typically occurs through transfer from food packaging, bioaccumulation in the food chain, and inhalation of household dust 4. PFOA is almost always detectable in serum5 and has been found in amniotic fluid,6, 7 maternal and umbilical cord blood,8, 9 and breast milk.10–13 Epidemiologic evidence on PFOA exposure and child development is limited, with variation in exposure timing and specific endpoints. In the Danish National Birth Cohort (n=1,400), prenatal PFOA levels were unrelated to maternal reports of child development through age 7.14, 15 Three cross-sectional studies observed divergent associations among measures of attention in school-age children. In the National Health and Nutrition Examination Survey (NHANES; n=571), higher PFOA levels were associated with increased odds of parent-reported Attention Deficit/Hyperactivity Disorder (ADHD).16 In New York State, higher levels of several PFCs – although not PFOA – were associated with impulsivity (n=79).17 Using C8 Health Project data (n=10,546), the parent study of the present report, Stein and Savitz reported reduced odds of ADHD at the highest PFOA exposure level.18 We recently examined the children in the present report in a prospective study (n=320) of PFOA exposure and performance on neuropsychological tests.19 With increased childhood PFOA exposure there was a modest increase in intelligence quotient (IQ), decrease in behaviors typical of ADHD, and null associations with reading skills, math skills, and neuropsychological functioning. The current study complements the existing literature by providing a prospective examination of childhood PFOA concentration and mother and teacher report of child behavior assessed 3 – 4 years later at ages 6 – 12. In 2001, a group of residents from the West Virginia and Ohio communities surrounding a chemical plant near Parkersburg, West Virginia filed a class action lawsuit alleging health damage from drinking water supplies drawing from PFOA-contaminated groundwater.20 Geometric mean PFOA levels in this population were approximately 5 times the national average; exposure to most other PFCs reflected typical background levels. We invited a subset of children in the C8 Health Project to participate in a follow-up study assessing neurobehavioral development.

In animal studies, perfluorinated compounds affect fetal growth, development, viability, and postnatal growth. The limited epidemiologic findings on child neurobehavioral development are mixed.We recruited and evaluated 320 children who participated in the C8 Health Project, a 2005-2006 survey in a Mid-Ohio Valley community highly exposed to perfluorooctanoate (PFOA) through contaminated drinking water. We examined associations among estimated in utero PFOA exposure, measured childhood PFOA serum concentration, and subsequent performance on neuropsychological tests 3-4 years later at ages 6-12 years. We assessed Intelligence Quotient (IQ) reading and math skills, language, memory and learning, visual-spatial processing, and attention. All multivariable linear regression models were adjusted for age, sex, home environment, test examiner, and maternal IQ. Models with measured childhood PFOA were additionally adjusted for child body mass index.Children in the highest as compared with lowest quartile of estimated in utero PFOA had increases in Full Scale IQ (β 4.6, 95% confidence interval [CI] = 0.7-8.5) and decreases in characteristics of attention deficit/hyperactivity disorder as measured by the Clinical Confidence Index of Connors' Continuous Performance Test-II (β -8.5, 95% CI = -16.1 to -0.8). There were negligible associations between PFOA and reading or math skills or neuropsychological functioning.These results do not suggest an adverse association between the levels of PFOA exposure experienced by children in this cohort and their performance on neuropsychological tests.

Rescue and recovery workers responding to the 2001 collapse of the World Trade Center (WTC) sustained exposures to toxic chemicals and have elevated rates of multiple morbidities.Using data from the World Trade Center Health Program and the National Death Index for 2002-2011, we examined standardized mortality ratios (SMR) and proportional cancer mortality ratios (PCMR) with indirect standardization for age, sex, race, and calendar year to the U.S. general population, as well as associations between WTC-related environmental exposures and all-cause mortality.We identified 330 deaths among 28,918 responders (SMR 0.43, 95%CI 0.39-0.48). No cause-specific SMRs were meaningfully elevated. PCMRs were elevated for neoplasms of lymphatic and hematopoietic tissue (PCMR 1.76, 95%CI 1.06-2.75). Mortality hazard ratios showed no linear trend with exposure.Consistent with a healthy worker effect, all-cause mortality among responders was not elevated. There was no clear association between intensity and duration of exposure and mortality. Surveillance is needed to monitor the proportionally higher cancer mortality attributed to lymphatic/hematopoietic neoplasms.

The extent to which polyfluoroalkyl compounds (PFCs) are detectable in amniotic fluid is unknown. Using paired samples from 28 women, we compared the concentration of 8 PFCs measured in serum, the standard matrix for assessing human exposure, amniotic fluid from routine amniocentesis, and urine. Perfluorooctanoate (PFOA), perfluorononanoate (PFNA), perfluorooctane sulfonate (PFOS), and perfluorohexane sulfonate (PFHxS) were detected in all maternal serum samples. The number of amniotic fluid samples with detectable concentrations differed by PFC (PFOA n=24; PFNA n=10; PFOS n=9; PFHxS n=4). The correlation coefficient between maternal serum and amniotic PFC levels varied considerably by PFC (PFOA ρ=0.64, p

BACKGROUND: Perfluorooctanoic acid (PFOA) is a potential cause of adverse pregnancy outcomes, but previous studies have been limited by low exposures and small study size. OBJECTIVES: Using birth certificate information, we examined the relation between estimated PFOA exposure and birth outcomes in an area of West Virginia and Ohio whose drinking water was contaminated by a chemical plant. METHODS: Births in the study area from 1990 through 2004 were examined to generate case groups of stillbirth (n = 106), pregnancy-induced hypertension (n = 224), preterm birth (n = 3,613), term low birth weight (n = 918), term small-for-gestational-age (SGA) (n = 353), and a continuous measure of birth weight among a sample of term births (n = 4,534). A 10% sample of term births ≥ 2,500 g were selected as a source of controls (n = 3,616). Historical estimates of serum PFOA were derived from a previously developed fate and transport model. In a second study, we examined 4,547 area births linked to a survey with residential history data. RESULTS: In the analysis based only on birth records, we found no consistent evidence of an association between estimated PFOA exposure and stillbirth, pregnancy-induced hypertension, preterm birth, or indices of fetal growth. In the analysis of birth records linked to the survey, PFOA was unrelated to pregnancy-induced hypertension or preterm birth but showed some suggestion of an association with early preterm birth. Measures of growth restriction showed weak and inconsistent associations with PFOA. CONCLUSIONS: Based on the analysis using the health survey, these results provide little support for an effect of PFOA exposure on most pregnancy outcomes, except for early preterm birth and possibly fetal growth restriction.

BACKGROUND: There are limited data on the associations between maternal or newborn and child exposure to perfluoroalkyl acids (PFAAs), including perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS). This study provides an opportunity to assess the association between PFAA concentrations in mother-child pairs in a population exposed to PFOA via drinking water. \ud OBJECTIVES: We aimed to determine the relationship between mother-child PFAA serum concentrations and to examine how the child: mother ratio varies with child's age, child's sex, drinking-water PFOA concentration, reported bottled water use, and mother's breast-feeding intention. \ud METHODS: We studied 4,943 mother-child pairs (children, 1-19 years of age). The child: mother PFAA ratio was stratified by possible determinants. Results are summarized as geometric mean ratios and correlation coefficients between mother-child pairs, overall and within strata. \ud RESULTS: Child and mother PFOA and PFOS concentrations were correlated (r = 0.82 and 0.26, respectively). Up to about 12 years of age, children had higher serum PFOA concentrations than did their mothers. The highest child: mother PFOA ratio was found among children 5 years of age had significantly higher PFOA and PFOS child: mother ratios than did girls. \ud CONCLUSION: Concentrations of both PFOA and PFOS tended to be higher in children than in their mothers. This difference persisted until they were about 12 years of age for PFOA and at least 19 years of age for PFOS.

Purpose Smoking during pregnancy is strongly associated with increased risk of small for gestational age (SGA) and low birth weight, whereas elevated prepregnancy body mass index (BMI) is associated with a decreased risk of SGA and greater birth weight. We investigated the combined effect of prenatal smoking and prepregnancy BMI on risk of SGA and on birth weight. Methods A total of 34,928 singleton, term pregnancies in residents of New York City between 1995 and 2003 were evaluated in multivariable regression models of birth weight and risk of SGA. Results Increasing prepregnancy BMI reduced the risk of SGA and increased birth weight. The effect of prenatal smoking on birth weight and SGA diminished in women as their prepregnancy BMI increased, such that prenatal smoking did not significantly impact the risk of SGA among women who were overweight or obese before pregnancy. Prenatal smoking decreased mean birth weight by 187 g (95% confidence interval [CI] −337, −37) among underweight women, by 129 g(95% CI −170, −87) among normal weight women, by 46 g (95% CI −113, +20) among overweight women, and by 75 g (95% CI −162, +11) among obese women. Conclusions This study suggests that the effect of smoking during pregnancy on SGA and birth weight is present in underweight and normal weight women but markedly reduced among obese and overweight women.

Background: Perfluorinated compounds (PFCs) are persistent environmental pollutants. Toxicology studies demonstrate the potential for perfluorooctanoic acid (PFOA) and other PFCs to affect human growth and development. Attention deficit/hyperactivity disorder (ADHD) is a developmental disorder with suspected environmental and genetic etiology. Objectives: We examined the cross-sectional association between serum PFC concentration and parent or self-report of doctor-diagnosed ADHD with and without current ADHD medication. Methods: We used data from the C8 Health Project, a 2005–2006 survey in a Mid-Ohio Valley community highly exposed to PFOA through contaminated drinking water, to study non-Hispanic white children 5–18 years of age. Logistic regression models were adjusted for age and sex. Results: Of the 10,546 eligible children, 12.4% reported ADHD and 5.1% reported ADHD plus ADHD medication use. We observed an inverted J-shaped association between PFOA and ADHD, with a small increase in prevalence for the second quartile of exposure compared with the lowest, and a decrease for the highest versus lowest quartile. The prevalence of ADHD plus medication increased with perfluorohexane sulfonate (PFHxS) levels, with an adjusted odds ratio of 1.59 (95% confidence interval, 1.21–2.08) comparing the highest quartile of exposure to the lowest. We observed a modest association between perfluorooctane sulfonate and ADHD with medication. Conclusions: The most notable finding for PFOA and ADHD, a reduction in prevalence at the highest exposure level, is unlikely to be causal, perhaps reflecting a spurious finding related to the geographic determination of PFOA exposure in this population or to unmeasured behavioral or physiologic correlates of exposure and outcome. Possible positive associations between other PFCs and ADHD, particularly PFHxS, warrant continued investigation.