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Downloaded from by Guest on September 25, 2021 ARTICLES Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides WHAT’S KNOWN ON THIS SUBJECT: Exposure to AUTHORS: Maryse F. Bouchard, PhD,a,b David C. Bellinger, organophosphates has been associated with adverse effects on PhD,a,c Robert O. Wright, MD, MPH,a,d,e and Marc G. neurodevelopment, such as behavioral problems and lower Weisskopf, PhDa,e,f cognitive function. Studies have focused, however, on populations Departments of aEnvironmental Health and fEpidemiology, with high levels of exposure, relative to the general population. School of Public Health, Harvard University, Boston, Massachusetts; bDepartment of Environmental and Occupational Health, Faculty of Medicine, University of Montreal, Montreal, WHAT THIS STUDY ADDS: We conducted a study with 1139 Quebec, Canada; Departments of cNeurology and dPediatrics, children 8 to 15 years of age, representative of the US population. School of Medicine, Harvard University, and Boston Children’s The findings showed that children with higher urinary levels of Hospital, Boston, Massachusetts; and eChanning Laboratory, organophosphate metabolites were more likely to meet the Department of Medicine, School of Medicine, Harvard University, diagnostic criteria for ADHD. and Brigham and Women’s Hospital, Boston, Massachusetts KEY WORDS attention-deficit/hyperactivity disorder, pesticides, organophosphates, National Health and Nutrition Examination Survey ABBREVIATIONS abstract DAP—dialkyl phosphate OBJECTIVE: The goal was to examine the association between urinary DMAP—dimethyl alkylphosphate DEAP—diethyl alkylphosphate concentrations of dialkyl phosphate metabolites of organophosphates OR—odds ratio and attention-deficit/hyperactivity disorder (ADHD) in children 8 to 15 CI—confidence interval years of age. ADHD—attention-deficit/hyperactivity disorder NHANES—National Health and Nutrition Examination Survey METHODS: Cross-sectional data from the National Health and Nutrition DISC-IV—Diagnostic Interview Schedule for Children IV Examination Survey (2000–2004) were available for 1139 children, who PIR—poverty/income ratio were representative of the general US population. A structured inter- DSM-IV—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition view with a parent was used to ascertain ADHD diagnostic status, on The Canadian Institutes for Health Research played no role in the basis of slightly modified criteria from the Diagnostic and Statisti- the design and conduct of the study; collection, management, cal Manual of Mental Disorders, Fourth Edition. analysis, and interpretation of the data; and preparation, review, RESULTS: One hundred nineteen children met the diagnostic criteria and approval of the manuscript. for ADHD. Children with higher urinary dialkyl phosphate concentra- www.pediatrics.org/cgi/doi/10.1542/peds.2009-3058 tions, especially dimethyl alkylphosphate (DMAP) concentrations, were doi:10.1542/peds.2009-3058 more likely to be diagnosed as having ADHD. A 10-fold increase in DMAP Accepted for publication Feb 23, 2010 concentration was associated with an odds ratio of 1.55 (95% confi- Address correspondence to Maryse F. Bouchard, PhD, University dence interval: 1.14–2.10), with adjustment for gender, age, race/eth- of Montreal, Department of Environmental and Occupational Health, CP 6128 Succursale Centre-Ville, Montreal, QC H3C 3J7, nicity, poverty/income ratio, fasting duration, and urinary creatinine Canada. E-mail: [email protected] concentration. For the most-commonly detected DMAP metabolite, di- PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). methyl thiophosphate, children with levels higher than the median of Copyright © 2010 by the American Academy of Pediatrics detectable concentrations had twice the odds of ADHD (adjusted odds FINANCIAL DISCLOSURE: The authors have indicated they have ratio: 1.93 [95% confidence interval: 1.23–3.02]), compared with chil- no financial relationships relevant to this article to disclose. dren with undetectable levels. Funded by the National Institutes of Health (NIH). CONCLUSIONS: These findings support the hypothesis that organo- phosphate exposure, at levels common among US children, may con- tribute to ADHD prevalence. Prospective studies are needed to estab- lish whether this association is causal. Pediatrics 2010;125:e1270–e1277 e1270 BOUCHARD et al Downloaded from www.aappublications.org/news by guest on September 25, 2021 ARTICLES Approximately 40 organophosphate A few epidemiological studies sug- Children who received newborn care pesticides are registered with the US gested that organophosphate expo- in an ICU or premature nursery (n ϭ Environmental Protection Agency for sure was associated with adverse neu- 167) and those with birth weights of use in the United States.1 In 2001, 73 rodevelopmental outcomes, but no Ͻ2500 g (n ϭ 126) were excluded be- million pounds of organophosphates studies have addressed possible risks cause these are important risk factors were used in both agricultural and res- among children with average levels of for developmental disorders.17 We ex- idential settings. The Environmental exposure. By using data for a repre- cluded 24 children with extremely di- Protection Agency considers food, sentative sample of US children, we ex- lute urine (creatinine levels of Ͻ20 drinking water, and residential pesti- amined the cross-sectional associa- mg/dL) and 1 outlier with respect to cide use important sources of expo- tion between urinary DAP metabolite urinary DAP concentrations. Children sure.2 Residential pesticide use is com- concentrations and attention-deficit/ with missing data were excluded (pov- mon, but the major source of exposure hyperactivity disorder (ADHD) preva- erty/income ratio [PIR], n ϭ 43; fasting to pesticides for infants and children lence in children 8 to 15 years of age. duration, n ϭ 38; urinary creatinine would be the diet, according to the level, n ϭ 1). National Academy of Sciences.3 The METHODS US Pesticide Data Program’s 2008 Re- Study Design and Population ADHD Assessment port indicates that detectable concen- The National Health and Nutrition Ex- The Diagnostic Interview Schedule for trations of the organophosphate mala- amination Survey (NHANES) is a Children IV (DISC-IV), a structured diag- thion were found in 28% of frozen population-based, health survey of nostic interview designed for use in ep- blueberry samples, 25% of strawberry 18 noninstitutionalized US residents con- idemiological studies, was used to samples, and 19% of celery samples.4 ducted by the National Center for assess the presence of ADHD on the Children are generally considered to Health Statistics of the Centers for Dis- basis of slightly modified criteria from be at greatest risk from organophos- ease Control and Prevention. The the Diagnostic and Statistical Manual phate toxicity, because the developing NHANES uses a complex, multistage, of Mental Disorders, Fourth Edition 19 brain is more susceptible to neurotoxi- probability sampling design, with over- (DSM-IV). The interview was con- cants5 and the dose of pesticides per sampling of certain subgroups. Partic- ducted with the mother or another body weight is likely to be larger for ipants completed household surveys, caretaker over the telephone by children. Children 6 to 11 years of age which included questions about demo- trained interviewers, 2 to 3 weeks af- have the highest urinary concentra- graphic features and health history, ter the physical examination. The inter- tions of dialkyl phosphate (DAP) me- and blood and urine samples were col- view was conducted by bilingual inter- tabolites (markers of organophos- lected during physical examinations at viewers in English or Spanish. The phate exposure), compared with other mobile centers.16 We used data from DISC-IV has evidence of substantial va- 18 18 age groups in the US population.6 Chil- 2000–2004, years for which ADHD was lidity, reliability for both its English 20,21 dren have reduced expression of de- assessed in children 8 to 15 years of and Spanish versions, and success- toxifying enzymes, which contributes age; diagnoses were available for 3998 ful use via telephone in DSM-IV field tri- 22 to their vulnerability.7,8 Epidemiologi- children. Urinary DAP metabolite levels als. The use of DISC-IV data is re- cal studies linking exposure to organo- were measured for a random sub- stricted for confidentiality reasons; phosphates and neurodevelopment sample of the NHANES participants. therefore, we accessed the data have focused on populations with high From 2000 to 2002, the sampling rate through the National Center for Health levels of exposure, relative to the gen- was 50% for ages 6 to 11 years and Statistics Research Data Center. eral population.9,10 Prenatal organo- 33% for ages 12 to 15 years. From 2003 The DISC-IV scoring algorithms deter- phosphate exposure was associated to 2004, the sampling rate was 33% for mine ADHD diagnostic status for the with increased risk of pervasive devel- all ages. Measurements of urinary DAP previous year, as well as ADHD sub- opmental disorders, as well as delays levels were available for 1481 children type, that is, predominately inattentive in mental development at 2 to 3 years among those with ADHD diagnoses. subtype, predominately hyperactive/ of age.11,12 Postnatal organophosphate The NHANES was approved by the Na- impulsive subtype, or combined sub- exposure has been associated with be- tional Center for Health Statistics in- type. The diagnosis is based on the havioral
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