Public health programs may be seriously affected in periods of federal retrenchment. During these times, state-based strategies provide an alternate pathway for advancing public health. A 12-year campaign to secure state support for a network of Centers of Excellence in Children’s Environmental Health (CEH) promoting health of children across New York State is described. It was driven by rising rates of asthma, birth defects, developmental disorders, and other noncommunicable diseases in children; growing evidence associating hazardous environmental exposures with these conditions; and recognition that federal resources in CEH are insufficient. Critical campaign elements were (1) formation of a statewide coalition of academic health centers, health care providers, public health officials, community advocates, and other stakeholders; (2) bipartisan collaborations with legislative champions and government leaders; (3) assessment of the burden of developmental disorders and noncommunicable diseases associated with environmental exposures among children; (4) maps documenting the presence of environmental hazards in every county statewide; (5) iterative charting of a changing political landscape; and (6) persistence. The 2017 award of a 5-year, $10 million contract to establish Centers of Excellence in CEH demonstrates the value of this statewide strategy.

We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to find cures for cancer and to reduce cancer mortality in the USA. While mortality has declined for all cancers combined, the disease continues to have a devastating effect on too many families. Intensified federal efforts to prevent, diagnose, and treat cancer are fully justified, and we congratulate Vice President Biden and President Obama for focusing renewed national attention on the investments necessary to make accelerated progress against this dreaded disease.

With rising incidence rates reported for asthma, birth defects, neurodevelopmental disorders, obesity, type 2 diabetes, and preterm birth,1Akinbami L.J. Schoendorf K.C. Trends in childhood asthma: prevalence, health care utilization and mortality.Pediatrics. 2002; 110: 315-322Crossref PubMed Scopus (647) Google Scholar, 2Boyle C.A. Cordero J.F. Birth defects and disabilities: a public health issue for the 21st century.Am J Public Health. 2005; 95: 1884-1886Crossref PubMed Scopus (22) Google Scholar, 3CDC (Centers for Disease Control and Prevention) improved national prevalence estimates for 18 selected major birth defects—United States, 1999–2001.MMWR. 2006; 54: 1301-1305PubMed Google Scholar, 4Fox C.S. Pencina M.J. Meigs J.B. Vasan R.S. Levitzky Y.S. D'Agostino Sr., R.B. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study.Circulation. 2006; 113: 2914-2918Crossref PubMed Scopus (291) Google Scholar, 5Galvez M.P. Frieden T.R. Landrigan P.J. Obesity in the 21st century.Environ Health Perspect. 2003; 111: A684-A685Crossref PubMed Scopus (13) Google Scholar there has been a concomitant increase in the recognition of the importance of toxic chemicals in our environment.6Landrigan P.J. Kimmel C.A. Correa A. Eskenazi B. Children's health and the environment: public health issues and challenges for risk assessment.Environ Health Perspect. 2004; 112: 257-265Crossref PubMed Scopus (314) Google Scholar, 7CDC (Centers for Disease Control and Prevention) fourth national report on human exposure to environmental chemicals updated tables, 2012. Available at: http://www.cdc.gov/exposurereport/pdf/FourthReport_UpdatedTables_Feb2012.pdf. Accessed October 15, 2012.Google Scholar, 8Suh H.H. Bahadori T. Vallarino J. Spengler J.D. Criteria air pollutants and toxic air pollutants.Environ Health Perspect. 2000; 108: 625-633Crossref PubMed Scopus (118) Google Scholar, 9U.S. EPA Chemical Hazard Data Availability Study: what do we really know about the safety of high production volume chemicals?. U.S. Environmental Protection Agency, Office of Pollution Prevention and Toxic Substances, Washington, DC1998http://www.epa.gov/hpv/pubs/general/hazchem.pdfGoogle Scholar, 10Woodruff T.J. Grillo J. Schoendorf C. The relationship between selected causes of postneonatal infant mortality and particulate air pollution in the United States.Environ Health Perspect. 1997; 105: 608-612Crossref PubMed Scopus (320) Google Scholar In 1993, the National Academy of Sciences published a landmark report, Pesticides in the Diets of Infants and Children,11National Academy of Sciences Pesticides in the diets of infants and children. National Academy Press, Washington, DC1993Google Scholar which emphasized that children are both more exposed and particularly vulnerable. Exposures in utero and in the first few years of life have disproportionate effects.12Houlihan J, Kropp T, Wiles R, Gray S, Campbell C. BodyBurden: the pollution in newborns. Available at: http://ewg.org/reports_content/bodyburden2/pdf/bodyburden1_final_r2.pdf. Accessed October 15, 2012.Google Scholar, 13Salam M.T. Li Y.F. Langholz B. Gilliland F.D. Early-life environmental risk factors for asthma: findings from the Children's Health Study.Lancet. 2004; 363: 119-125Abstract Full Text Full Text PDF PubMed Scopus (299) Google Scholar Relative to their body weight, children breathe more air, drink more water, and eat more food than adults.14Landrigan P.J. Miodovnik A. Children's Health and the environment: an overview.Mt Sinai J Med. 2011; 78: 1-10Crossref PubMed Scopus (50) Google Scholar Children are closer to the ground, play vigorously outdoors, and their higher body surface to volume ratio and normal hand to mouth behavior increase their exposure.15Landrigan P.J. Rauh V.A. Galvez M.P. Environmental justice and the health of children.Mt Sinai J Med. 2010; 77: 178-187Crossref PubMed Scopus (91) Google Scholar Young children have immature immune systems and may be less able to metabolize toxicants or ameliorate the potential effects of carcinogens, including ionizing radiation.16Brent R. Weitzman M. Balk S. Lanphear B. Landrigan P.J. Reigart R. The vulnerability, sensitivity, and resiliency of the developing embryo, infant, child, and adolescent to the effects of environmental chemicals, drugs, and physical agents as compared to adults.Pediatrics. 2004; 113: 932aCrossref PubMed Scopus (12) Google Scholar Malignancies, cardiovascular, and neurodegenerative diseases may take decades to develop, so young children have the longest lifetime for consequences of early exposures to become apparent.17Ekbom A. Hsieh C.C. Lipworth L. Adami H.Q. Trichopoulos D. Intrauterine environmental and breast cancer risk in women: a population-based study.J Natl Cancer Inst. 1997; 89: 71-76Crossref PubMed Scopus (212) Google Scholar The growing appreciation of epigenetics raises concerns that environmental exposures may effect not just today's children, but also our children's children.18Perera F. Herbstman J. Prenatal environmental exposures, epigenetics, and disease.Reprod Toxicol. 2011; 31: 363-373Crossref PubMed Scopus (449) Google Scholar Our understanding of the complexities of the relationships between the environment and children's health should significantly increase with the full implementation of The National Children's Study, a broad-ranging 21-year prospective study designed to improve our ability to assess, prevent, and treat adverse effects of environmental exposures.19Landrigan P.J. Trasande L. Thorpe L.E. Gwynn C. Lioy P.J. D'Alton M.E. et al.The National Children's Study: a 21-year prospective study of 100 000 American children.Pediatrics. 2006; 118: 2173-2186Crossref PubMed Scopus (150) Google Scholar The field of children's environmental health is growing worldwide,20Gavidia T.G. Pronczuk-Garbino J. Sly P.D. Children's environmental health: an under-recognized area in paediatric health care.BMC Pediatrics. 2009; 9: 10Crossref PubMed Scopus (9) Google Scholar, 21Neira M. Gore F. Brune M.N. Hudson T. Pronczuk-Garbino J. Environmental threats to children's health–a global problem.Int J Environ Health. 2008; 2: 276-292Crossref Scopus (6) Google Scholar, 22Seidel H.J. Environmental medicine in Germany–a review.Environ Health Perspect. 2002; 110: 113-118Crossref PubMed Scopus (12) Google Scholar, 23Firestone M.P. Amler R.W. Children's environmental health–an international perspective.Int J Hyg Environ Health. 2003; 206: 395-400Crossref PubMed Scopus (9) Google Scholar and the World Health Organization recognizes the need for more research.24Pruss-Ustun A. Corvalan C. Preventing disease through healthy environments: towards an estimate of the environmental burden of disease. World Health Organization, Geneva2006Google Scholar Understanding the relationship between global climate change and health promises to be an important focus well into the future.25Diarmid Campbell-Lendrum Carlos Corvalán Maria Neira Global climate change: implications for international public health policy.Bull World Health Organ. 2007; 85: 235-237Crossref PubMed Scopus (64) Google Scholar, 26Sheffield P.E. Landrigan P.J. Global climate change and children's health: threats and strategies for prevention.Environ Health Perspect. 2010; 119: 291-298Crossref PubMed Scopus (256) Google Scholar The Institute of Medicine has recommended that environmental health should be part of medical education at all levels,27IOM (Institute of Medicine) Environmental Medicine Integrating a missing element into medical education. National Academy Press, Washington, DC1995Google Scholar and several governmental and non-governmental efforts have addressed this need. The not-for-profit Children's Environmental Health Network began such efforts in the early 1990s.28Etzel R.A. Developmental milestones in children's environmental health.Environ Health Perspect. 2010; 118: A420-A421Crossref PubMed Scopus (1) Google Scholar The Agency for Toxic Substances and Disease Registry (ATSDR), a part of the Centers for Disease Control and Prevention, organized a national child health initiative in 1996 that focused the agency's physician education efforts.29Smith L. Amler R.W. ATSDR inventory of child health activities–1998-1999. US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, Atlanta1999Google Scholar, 30Amler R.W. Ramsey T.L. Young P.Y. ATSDR inventory of child health activities–1997. US Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, Atlanta1997Google Scholar, 31Amler S. DeRosa C.T. Williams-Johnson M.M. Jones D.E. Amler R.W. Risk analysis, uncertainty factors, and the susceptibilities of children.J Human Ecol Risk Assess. 2003; 9: 1701-1712Crossref Scopus (7) Google Scholar, 32Amler R. Amler S. Balk S.J. McLellan R.K. Case studies in environmental medicine: pediatric environmental health. US Dept of Health and Human Services, Agency for Toxic Substances and Disease Registry, AtlantaJuly 2002Google Scholar In 1997, the US Environmental Protection Agency (EPA) formed an Office of Children's Health and the White House launched a multi-agency Task Force on Children's Environmental Health Risks and Safety Risks.33Executive Office of the President. Executive Order 13045, April 21, 1997. Washington: Federal Register 62(78):19885-8.Google Scholar, 34Amler R.W. The public health approach to children's health and environmental hazards in the United States of America.in: v.Mühlendahl K.E. Schulte im Walde J. Kinderumwelt und gesundheit: status–defizite–handlungsvorschläge. Sympsium Potsdam, 2001. Robert Koch Institute, Berlin2001: 49-54Google Scholar Government agencies have collaborated with the American Academy of Pediatrics, Children's Environmental Health Network, and a variety of non-governmental organizations to develop quality educational materials for healthcare providers. Nonetheless education remains spotty.35Kilpatrick N. Frumkin H. Trowbridge J. Escoffery C. Geller R. Rubin L. et al.The environmental history in pediatric practice: a study of pediatricians' attitudes, beliefs, and practices.Environ Health Perspect. 2002; 110: 823-827Crossref PubMed Scopus (65) Google Scholar, 36Trasande L. Schapiro M.L. Falk R. Haynes K.A. Behrmann A. Vohmann M. et al.Pediatrician attitudes and knowledge of environmental health in Wisconsin.Wis Med J. 2006; 105: 50-54Google Scholar Few pediatricians are adequately trained or experienced in interpreting the avalanche of information about potential environmental challenges.37Hu H. Woolf A. Environmental medicine as an emerging discipline.Environ Health Perspect. 2003; 111: 1-3PubMed Google Scholar, 38Woolf A. Cimino S. Environmental illness: educational needs of pediatric care providers.Exp Ped Educ Prac. 2001; 7: 43-51Google Scholar Pediatricians need to incorporate an environmental history into their practices and perform age-appropriate risk assessment. And when a potential environmental disease trigger is identified, what then? Parents will increasingly seek competent guidance, and pediatricians need advice from experts in children's environmental health. Fortunately, resources are becoming increasingly available, including a clinician's handbook published by the American Academy of Pediatrics, Pediatric Environmental Health, now in its third edition.39American Academy of Pediatrics Committee on Environmental Health Etzel R.A. Balk S.J. Pediatric Environmental Health, 3rd ed. American Academy of Pediatrics, Elk Gove Village, IL2011Google Scholar Grand rounds, seminars, webinars, and government reports continue to proliferate, and the fund of knowledge is steadily growing. A new textbook on children's environmental health, edited by Philip Landrigan and Ruth Etzel, is scheduled for publication (personal communication with Philip J. Landrigan, June 2012). A small number of pediatricians are developing a special focus on "Environmental Pediatrics" or "Children's Environmental Health." Perhaps the most ambitious educational funding was a program launched in 2001 by the Ambulatory Pediatric Association, encouraging formal 3-year fellowships at 5 academic medical centers: Boston Children's Hospital, Mount Sinai School of Medicine, George Washington University, University of Cincinnati, and University of Washington. Twenty-seven competencies for fellows in pediatric environmental health were proposed.40Etzel R.A. Crain E.F. Gitterman B.A. Oberg C. Scheidt P. Landrigan P.J. Pediatric environmental health competencies for specialists.Ambul Pediatr. 2003; 3: 60-63Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar In the first 5 years, 17 fellows had entered these programs, most of whom successfully completed their training and took their places as leaders of this nascent subspecialty.41Landrigan P.J. Woolf A.D. Gitterman B. Lanphear B. Forman J. Karr C. et al.The ambulatory pediatric association fellowship in pediatric environmental health: a 5-year assessment.Environ Health Perspect. 2007; 115: 1383-1387PubMed Google Scholar The Ambulatory Pediatric Association continues to be active in this regard and plans to start accrediting fellowships in Children's Environmental Health. A list of current training programs is in the Table.TableFellowships in children's environmental healthProgramHospital and Academic AffiliationLocationEnvironmental HealthBoston Children's Hospital and Harvard Medical SchoolBoston, MassachusettsEnvironmental PediatricsMt. Sinai Medical Center and School of MedicineNew York, New YorkFellowship in Child and Adolescent Health Research with a focus on Children's Environmental HealthCincinnati Children's Hospital and University of CincinnatiCincinnati, OhioGeneral Pediatric Fellowship with Pediatric Environmental Health OptionUniversity of California, San FranciscoSan Francisco, CaliforniaAmerican Academy of PediatricsPediatric Environmental Health and Food Policy FellowAmerican Academy of PediatricsWashington, District of ColumbiaPediatric Environmental Health Sciences FellowshipMedical College of WisconsinMilwaukee, WisconsinGeneral Academic Pediatric Fellowship with focus on Environmental HealthUniversity of WashingtonSeattle, Washington Open table in a new tab Children's Environmental Health Centers have sprung up throughout the US and beyond.42Spivey A. Children's health centers: past, present, and future.Environ Health Perspect. 2007; 115: A192-A194Crossref PubMed Scopus (8) Google Scholar, 43Shannon M. Woolf A. Goldman R. Children's environmental health: one year in a pediatric environmental health specialty unit.Ambul Pediatr. 2003; 3: 53-56Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar ATSDR's Child Health Initiative launched a national network of Pediatric Environmental Health Specialty Unit (PEHSU), funded jointly by ATSDR and the EPA.44Paulson J.A. Karr C.J. Seltzer J.M. Cherry DC. Sheffield PE. Cifuentes E. et al.Development of the pediatric environmental health specialty unit network in North America.Am J Public Health. 2009; 99: S511-S516Crossref PubMed Google Scholar PEHSU are clinical facilities that operate collaboratively between academic pediatric programs and clinics certified by the Association of Occupational and Environmental Clinics, offering consultative, educational, and referral services to clinicians and communities. At least 1 PEHSU operates in each of 10 federally defined regions in the US, Canada, and Mexico, and several other countries outside North America (information available at http://www.aoec.org/pehsu/documents/pehsu_program_overview_december_2011.pdf). In addition, Children's Environmental Health and Disease Prevention Research Centers,45NIEHS/EPA Children's Environmental Health and Disease Prevention Research Centers: protecting children's health for a lifetime. Available at: http://www.niehs.nih.gov/. Accessed October 15, 2012.Google Scholar jointly supported since 1998 by the National Institute of Environmental Health Sciences and the EPA, are located at 14 sites as of 2011 (information available at http://www.niehs.nih.gov/reesearch/supported/centers/prevention/grantees/index.cfm). It is no longer possible to open up a newspaper (or social media feed), without reading about another environmental concern for children–climate change, hydraulic fracturing, tsunamis, wild fires, metals in jewelry, excess medical radiation, flame-retardants, endocrine disruptors, fetal alcohol exposure, air pollution, and first-hand, second-hand, and now third-hand tobacco smoke.46Becquemin M.H. Bertholon J.F. Bentayeb M. Attoui M. Ledur D. Roy F. et al.Third-hand smoking: indoor measurements of concentration and sizes of cigarette smoke particles after resuspension.Tob Control. 2010; 19: 347-348Crossref PubMed Scopus (50) Google Scholar One important function of children's environmental health centers is to dispassionately interpret the news for anxious parents, families, healthcare providers, governments, and the community. Pediatricians have a unique and vital role in the development of national and international policies meant to balance the risks and benefits of chemicals in the environment.47Landrigan P.J. Goldman L.R. Children's vulnerability to toxic chemicals: a challenge and opportunity to strengthen health and environmental policy.Health Affairs. 2011; 30: 842-850Crossref PubMed Scopus (201) Google Scholar Pediatricians drawn to the field hail from a wide variety of backgrounds, including teratology, lead poisoning, poison control, community health, neonatology, and pediatric pulmonology. Although there is a clear and compelling need for experts in this field to teach medical students, residents, and other health professionals, is further subspecialization of pediatrics desirable? No one can turn back the clock, but subdividing into smaller and smaller pieces raises concern for the future of general pediatrics, which is, after all, already a specialty. Thoughtful commentaries have been written lamenting the loss of the Oslerian tradition of the general physician caring for the "whole person" and the inevitable loss of this role model for young physicians.48Huddle T.S. Centor R. Heudebert G.R. American Internal Medicine in the 21st century: can an Oslerian generalism survive?.J Gen Intern Med. 2003; 18: 764-767Crossref PubMed Scopus (20) Google Scholar, 49Cassel C.K. Reuben D.B. Specialization, subspecialization, and subsubspecialization in internal medicine.N Engl J Med. 2011; 364: 1169-1173Crossref PubMed Scopus (108) Google ScholarThere is a distinct difference between the time-honored tradition of physicians becoming absorbed in a certain segment of medical science and developing expertise in that area and the need for official certification by the American Board of Medical Specialties.50American Board of Medical Specialties. Application for subspecialty certificate. Available at: http://www.abms.org. Accessed October 15, 2012.Google Scholar Children's Environmental Health may not warrant board certification, but experts certainly are needed. Pediatricians interested in developing expertise should be encouraged to pursue advanced public health degrees (MPH and DPH), which often can be obtained before, during, or after medical school, pediatric residency, or subspecialty fellowship. Academic departments will surely seek out pediatricians with expertise as they incorporate Children's Environmental Health into their curricula. The authors gratefully acknowledge the suggestions and advice of Philip J. Landrigan, MD, and James A. Stockman, MD, during the preparation of this commentary, and Leonard J. Newman, MD, for reviewing the manuscript.

Training in environmental health in general, and pediatric environmental health in particular, is inadequate. The Agency for Toxic Substances and Disease Registry began to develop pediatric environmental health specialty units (PEHSUs) after noting the dearth of practitioners who could evaluate and manage children with exposures to environmental health hazards. The Environmental Protection Agency subsequently joined in providing support for what has developed into a network of 13 PEHSUs in North America. PEHSUs provide services to families, act as consultants to clinicians and public agencies, develop educational materials, and respond to natural disasters, including hurricanes and wildfires. PEHSUs are relatively easy to organize and should be replicable internationally.

Context Private wells that tap groundwater are largely exempt from federal drinking-water regulations, and in most states well water is not subject to much of the mandatory testing required of public water systems. Families that rely on private wells are thus at risk of exposure to a variety of unmeasured contaminants. Case Presentation A family of seven—two adults and five children—residing in rural northwestern Connecticut discovered elevated concentrations of uranium in their drinking water, with levels measured at 866 and 1,160 μg/L, values well above the U.S. Environmental Protection Agency maximum contaminant level for uranium in public water supplies of 30 μg/L. The uranium was of natural origin, and the source of exposure was found to be a 500-foot well that tapped groundwater from the Brookfield Gneiss, a geologic formation known to contain uranium. Other nearby wells also had elevated uranium, arsenic, and radon levels, though concentrations varied widely. At least one 24-hr urine uranium level was elevated (> 1 μg/24 hr) in six of seven family members (range, 1.1–2.5 μg/24 hr). To assess possible renal injury, we measured urinary beta-2-microglobulin. Levels were elevated (> 120 μg/L) in five of seven family members, but after correction for creatine excretion, the beta-2-microglobulin excretion rate remained elevated (> 40 μg/mmol creatinine) only in the youngest child, a 3-year-old with a corrected level of 90 μg/mmol creatinine. Three months after cessation of well water consumption, this child’s corrected beta-2-microglobulin level had fallen to 52 μg/mmol creatinine. Significance This case underscores the hazards of consuming groundwater from private wells. It documents the potential for significant residential exposure to naturally occurring uranium in well water. It highlights the special sensitivity of young children to residential environmental exposures, a reflection of the large amount of time they spend in their homes, the developmental immaturity of their kidneys and other organ systems, and the large volume of water they consume relative to body mass.

The American Academy of Pediatrics’ Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, reviewed and analyzed the current literature for the purpose of developing an evidence-based clinical practice guideline for the treatment of the school-aged child with attentiondeficit/hyperactivity disorder (ADHD). This review included several key reports, including an evidence review from the McMaster Evidence-Based Practice Center (supported by the Agency for Healthcare Research and Quality), a report from the Canadian Coordinating Office for Health Technology Assessment, the Multimodal Treatment for ADHD comparative clinical trial (supported by the National Institute of Mental Health), and supplemental reviews conducted by the subcommittee. These reviews provided substantial information about different treatments for ADHD and their efficacy in improving certain characteristics or outcomes for children with ADHD as well as adverse effects and benefits of multiple modes of treatment compared with single modes (eg, medication or behavior therapies alone). The reviews also compared the effects of different medications. Other evidence documents the long-term nature of ADHD in children and its classification as a chronic condition, meriting the application of general concepts of chronic-condition management, including an individual treatment plan with a focus on ongoing parent and child education, management, and monitoring. The evidence strongly supports the use of stimulant medications for treating the core symptoms of children with ADHD and, to a lesser degree, for improving functioning. Behavior therapy alone has only limited effect on symptoms or functioning of children with ADHD, although combining behavior therapy with medication seems to improve functioning and may decrease the amount of (stimulant) medication needed. Comparison among stimulants (mainly methylphenidate and amphetamines) did not indicate that 1 class outperformed the other. Pediatrics 2005;115:e749–e757. URL: www.pediatrics.org/cgi/doi/10.1542/peds.; attentiondeficit hyperactivity disorder, stimulant medication, multimodal treatment, behavior management, co-occurring. ABBREVIATIONS. AAP, American Academy of Pediatrics; ADHD, attention-deficit/hyperactivity disorder; MTA, Multimodal Treatment Study for Children With ADHD; MPH, methylphenidate; DEX, dexedrine; PEM, pemoline; RCT, randomized, controlled trial. INTRODUCTION The American Academy of Pediatrics’ (AAP) Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, developed a clinical practice guideline pertaining to the treatment of school-aged children with attention-deficit/hyperactivity disorder (ADHD).1,2 The review here covers the additional evidence gathered for and by the subcommittee regarding specific treatments for ADHD. It does not include more recent studies published since the publication of the guideline in 2001. Other evidence supports the notion that ADHD is a chronic health condition meriting the application of general principles of management of childhood chronic conditions by primary care clinicians. Longitudinal studies of Barkley et al3 and Biederman et al4 document the persistence of the condition over time. Previous policy statements by the AAP describe the elements of chronic-condition care, including educating parents and children about illness, developing individual treatment plans, helping to coordinate multiple services, and encouraging parents to have contact with other parents of children with chronic conditions. Because ADHD has pervasive effects on the child’s daily life, including school performance, a partnership of clinicians and school personnel will help ensure the child’s best progress and proper assessment of progress. This report summarizes the empirical literature on which the practice guideline’s recommendation for pharmacologic and/or behavioral intervention was based. Certain other aspects of clinical care have not been the focus of careful clinical trials or randomized, controlled studies to determine accurately optimal practices. Thus, many of these recommendations reflect consensus of best practices. The specific areas included in these consensus recommendations include (1) the best specific ways of titrating a child’s medications, (2) the frequency of monitoring visits during titration phases and after stabilization, or (3) the specific content of monitoring. Again, these recommendations reflect assessment of best practices in long-term care. Four main sources of data were examined in developing these treatment recommendations. The McMaster University Evidence-Based Practice Center (under contract with the Agency for Healthcare Redoi:10.1542/peds.2004-2560 PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Academy of Pediatrics. www.pediatrics.org/cgi/doi/10.1542/peds. PEDIATRICS Vol. 115 No. 6 June 2005 e749 at Swets Blackwell 75204703 on March 11, 2007 www.pediatrics.org Downloaded from search and Quality and in partnership with the AAP and other organizations) reviewed the shortand long-term efficacy and safety of pharmacologic and nonpharmacologic interventions for ADHD and the comparative efficacy of single versus combined treatments. For a full account of the evidence, see the technical report compiled by the former Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality).5 The second source was a review of interventions for ADHD conducted by the Center for Community Health Research, British Columbia Research Institute for Children’s and Women’s Health, and the University of British Columbia6 for the Canadian Coordinating Office of Health Technology Assessment. The third source included the findings from the multisite treatment study conducted by the Multimodal Treatment Study for Children With ADHD (the MTA Cooperative Group),7,8 which is supported by the National Institute of Mental Health. After reviewing the findings and conclusions of the 3 sources listed above, the subcommittee conducted an additional search of the available literature to assess further the effectiveness of behavioral interventions both as stand-alone regimens and in combination with pharmacologic treatments. This search selected published reports of trials of behavior therapies in groups of school-aged children with ADHD. Individual case reports were excluded. The evidence from this search was compiled and evaluated by the subcommittee. McMASTER UNIVERSITY EVIDENCE-BASED PRACTICE CENTER REVIEW The goals of the evidence-based review conducted by the McMaster University Evidence-Based Practice Center Group5 were to examine the efficacy of nonstimulant medications and nonpharmacologic interventions for ADHD in children and adults and to examine the comparative efficacy of combined versus individual interventions. The technical review examined (1) drug-to-drug comparisons of specific stimulant medications, (2) stimulants versus antidepressant medications, and (3) comparisons of different forms of the same medication. The stimulant drugs examined were methylphenidate (MPH), dexedrine (DEX), and pemoline (PEM). The review also compared tricyclic antidepressants versus placebo and pharmacologic versus nonpharmacologic interventions. The report also examined long-term studies with a duration of 12 or more weeks. Final categories reviewed were studies examining the treatment of ADHD in adults, treatment combinations, and the adverse effects of pharmacologic interventions. This article reviews only findings pertaining to treatment of ADHD among school-aged children. The McMaster review selected a total of 92 empirical articles reflecting 78 investigations from a pool of 2405 citations compiled from traditional databases (Medline, Cinahl, HealthStar, PsychINFO, Embase), The Cochrane Library (1997, issue 4), reference lists of articles identified in the previous sources, and additional citations suggested by members of the McMaster research team and partnering organizations. Two reviewers independently rated each article to determine the quality of the methodology used in the study. Studies were included in the evidence-based review if they were randomized, controlled trial (RCTs), involved human subjects, and were published as a full report in a peer-reviewed journal. Studies that included participants with diagnoses other than ADHD (eg, oppositional defiant disorder, conduct disorder) were included in the review only if the study provided a separate analysis for the study participants with ADHD. A problem identified by the review team and associated organizations was the diversity of outcomes used in these many studies. Some studies used indicators or core symptoms of ADHD; others examined aspects of school or social behavior or behaviors at home. This diversity makes clear comparisons among treatment regimens difficult. The McMaster review noted important methodologic limitations in the numerous studies examining interventions for ADHD spanning a period of more than 25 years. Major limitations included small sample sizes and the use of heterogeneous outcome measures. The review found few studies in most of the study areas. Drug-to-Drug Comparisons Twenty-three studies on specific drug-to-drug comparisons were included in the review. These included studies comparing different stimulant medications: 8 studies compared MPH and DEX,9–17 2 compared MPH and PEM,18,19 and 1 compared DEX and PEM.20 Three studies compared a stimulant drug and a tricyclic antidepressant. One study compared MPH and desipramine,21 and 2 compared MPH and imipramine.22,23 Also included were studies comparing different formulations of the same drug. Three studies compared regular and sustainedrelease formulations of MPH,24–26 and 1 study compared different isomers of MPH (l-MPH versus d-MPH).27 Finally, 1 study compared DEX and levoamphetamine.9 The stimulant-stimulant comparisons docume

Neurodevelopmental disabilities affect 3-8% of the 4 million babies born each year in the U.S. alone, with known etiology for less than 25% of those disabilities. Numerous investigations have sought to determine the role of environmental exposures in the etiology of a variety of human neurodevelopmental disorders (e.g., learning disabilities, attention deficit-hyperactivity disorder, intellectual disabilities) that are manifested in childhood, adolescence, and young adulthood. A comprehensive critical examination and discussion of the various methodologies commonly used in investigations is needed. The Hershey Medical Center Technical Workshop: Optimizing the design and interpretation of epidemiologic studies forassessing neurodevelopmental effects from in utero chemical exposure provided such a forum for examining these methodologies. The objective of the Workshop was to develop scientific consensus on the key principles and considerations for optimizing the design and interpretation of epidemiologic studies of in utero exposure to environmental chemicals and subsequent neurodevelopmental effects. (The Panel recognized that the nervous system develops post-natally and that critical periods of exposure can span several developmental life stages.) Discussions from theWorkshop Panel generated 17 summary points representing key tenets of work in this field. These points stressed the importance of:center dot a well-defined, biologically plausible hypothesis as the foundation of in utero studies for assessing neurodevelopmental outcomes;center dot understanding of the exposure to the environmental chemical(s) of interest, underlying mechanisms of toxicity, and anticipated outcomes;center dot the use of a prospective, longitudinal cohort design that, when possible, runs for periods of 2-5 years, and possibly even longer, in an effort to assess functions at key developmental epochs;center dot measuring potentially confounding variables at regular, fixed time intervals;center dot including measures of specific cognitive and social-emotional domains along with non-cognitive competence in young children, as well as comprehensive measures of health;center dot consistency of research design protocols across studies (i.e., tests, covariates, and analysis styles) in an effort to improve interstudy comparisons;center dot emphasis on design features that minimize introduction of systematic error at all stages of investigation: participant selection, data collection and analysis, and interpretation of results; these would include (but not be limited to) reducing selection bias, using double-blind designs, and avoiding post hoc formulation of hypotheses;center dot a priori data analysis strategies tied to hypotheses and the overall research design, particularly for methods used to characterize and address confounders in any neurodevelopmental study;center dot actual quantitative measurements of exposure, even if indirect, rather than methods based on subject recall;center dot careful examination of standard test batteries to ensure that the battery is tailored to the age group as well as what is known about the specific neurotoxic effects on the developing nervous system;center dot establishment of a system for neurodevelopmental surveillance for tracking the outcomes from in utero exposure across early developmental time periods to determine whether central nervous system injuries may be lying silent until developmentally challenged;center dot ongoing exploration of computerized measures that are culturally and linguistically sensitive, and span the age range from birth into the adolescent years;center dot routine incorporation of narrative in manuscripts concerning the possibility of spurious (i.e., false positive and false negative) test results in all research reportage (this can be facilitated by detailed, transparent reporting of design, covariates, and analyses so that others can attempt to replicate the study);center dot forthright, disciplined, and intellectually honest treatment of the extent to which results of any study are conclusive - that is, how generalizable the results of the study are in terms of the implications for the individual study participants, the community studied, and human health overall;center dot confinement of reporting to the actual research questions, how they were tested, and what the study found, and avoiding, or at least keeping to a minimum, any opinions or speculation concerning public health implications;center dot education of clinicians and policymakers to critically read scientific reports, and to interpret study findings and conclusions appropriately; andcenter dot recognition by investigators of their ethical duty to report negative as well as positive findings, and the importance of neither minimizing nor exaggerating these findings.(C) 2006 Elsevier Inc. All rights reserved.

The American Academy of Pediatrics’ Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, reviewed and analyzed the current literature for the purpose of developing an evidence-based clinical practice guideline for the treatment of the school-aged child with attentiondeficit/hyperactivity disorder (ADHD). This review included several key reports, including an evidence review from the McMaster Evidence-Based Practice Center (supported by the Agency for Healthcare Research and Quality), a report from the Canadian Coordinating Office for Health Technology Assessment, the Multimodal Treatment for ADHD comparative clinical trial (supported by the National Institute of Mental Health), and supplemental reviews conducted by the subcommittee. These reviews provided substantial information about different treatments for ADHD and their efficacy in improving certain characteristics or outcomes for children with ADHD as well as adverse effects and benefits of multiple modes of treatment compared with single modes (eg, medication or behavior therapies alone). The reviews also compared the effects of different medications. Other evidence documents the long-term nature of ADHD in children and its classification as a chronic condition, meriting the application of general concepts of chronic-condition management, including an individual treatment plan with a focus on ongoing parent and child education, management, and monitoring. The evidence strongly supports the use of stimulant medications for treating the core symptoms of children with ADHD and, to a lesser degree, for improving functioning. Behavior therapy alone has only limited effect on symptoms or functioning of children with ADHD, although combining behavior therapy with medication seems to improve functioning and may decrease the amount of (stimulant) medication needed. Comparison among stimulants (mainly methylphenidate and amphetamines) did not indicate that 1 class outperformed the other. Pediatrics 2005;115:e749–e757. URL: www.pediatrics.org/cgi/doi/10.1542/peds.; attentiondeficit hyperactivity disorder, stimulant medication, multimodal treatment, behavior management, co-occurring. ABBREVIATIONS. AAP, American Academy of Pediatrics; ADHD, attention-deficit/hyperactivity disorder; MTA, Multimodal Treatment Study for Children With ADHD; MPH, methylphenidate; DEX, dexedrine; PEM, pemoline; RCT, randomized, controlled trial. INTRODUCTION The American Academy of Pediatrics’ (AAP) Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, developed a clinical practice guideline pertaining to the treatment of school-aged children with attention-deficit/hyperactivity disorder (ADHD).1,2 The review here covers the additional evidence gathered for and by the subcommittee regarding specific treatments for ADHD. It does not include more recent studies published since the publication of the guideline in 2001. Other evidence supports the notion that ADHD is a chronic health condition meriting the application of general principles of management of childhood chronic conditions by primary care clinicians. Longitudinal studies of Barkley et al3 and Biederman et al4 document the persistence of the condition over time. Previous policy statements by the AAP describe the elements of chronic-condition care, including educating parents and children about illness, developing individual treatment plans, helping to coordinate multiple services, and encouraging parents to have contact with other parents of children with chronic conditions. Because ADHD has pervasive effects on the child’s daily life, including school performance, a partnership of clinicians and school personnel will help ensure the child’s best progress and proper assessment of progress. This report summarizes the empirical literature on which the practice guideline’s recommendation for pharmacologic and/or behavioral intervention was based. Certain other aspects of clinical care have not been the focus of careful clinical trials or randomized, controlled studies to determine accurately optimal practices. Thus, many of these recommendations reflect consensus of best practices. The specific areas included in these consensus recommendations include (1) the best specific ways of titrating a child’s medications, (2) the frequency of monitoring visits during titration phases and after stabilization, or (3) the specific content of monitoring. Again, these recommendations reflect assessment of best practices in long-term care. Four main sources of data were examined in developing these treatment recommendations. The McMaster University Evidence-Based Practice Center (under contract with the Agency for Healthcare Redoi:10.1542/peds.2004-2560 PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Academy of Pediatrics. www.pediatrics.org/cgi/doi/10.1542/peds. PEDIATRICS Vol. 115 No. 6 June 2005 e749 search and Quality and in partnership with the AAP and other organizations) reviewed the shortand long-term efficacy and safety of pharmacologic and nonpharmacologic interventions for ADHD and the comparative efficacy of single versus combined treatments. For a full account of the evidence, see the technical report compiled by the former Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality).5 The second source was a review of interventions for ADHD conducted by the Center for Community Health Research, British Columbia Research Institute for Children’s and Women’s Health, and the University of British Columbia6 for the Canadian Coordinating Office of Health Technology Assessment. The third source included the findings from the multisite treatment study conducted by the Multimodal Treatment Study for Children With ADHD (the MTA Cooperative Group),7,8 which is supported by the National Institute of Mental Health. After reviewing the findings and conclusions of the 3 sources listed above, the subcommittee conducted an additional search of the available literature to assess further the effectiveness of behavioral interventions both as stand-alone regimens and in combination with pharmacologic treatments. This search selected published reports of trials of behavior therapies in groups of school-aged children with ADHD. Individual case reports were excluded. The evidence from this search was compiled and evaluated by the subcommittee. McMASTER UNIVERSITY EVIDENCE-BASED PRACTICE CENTER REVIEW The goals of the evidence-based review conducted by the McMaster University Evidence-Based Practice Center Group5 were to examine the efficacy of nonstimulant medications and nonpharmacologic interventions for ADHD in children and adults and to examine the comparative efficacy of combined versus individual interventions. The technical review examined (1) drug-to-drug comparisons of specific stimulant medications, (2) stimulants versus antidepressant medications, and (3) comparisons of different forms of the same medication. The stimulant drugs examined were methylphenidate (MPH), dexedrine (DEX), and pemoline (PEM). The review also compared tricyclic antidepressants versus placebo and pharmacologic versus nonpharmacologic interventions. The report also examined long-term studies with a duration of 12 or more weeks. Final categories reviewed were studies examining the treatment of ADHD in adults, treatment combinations, and the adverse effects of pharmacologic interventions. This article reviews only findings pertaining to treatment of ADHD among school-aged children. The McMaster review selected a total of 92 empirical articles reflecting 78 investigations from a pool of 2405 citations compiled from traditional databases (Medline, Cinahl, HealthStar, PsychINFO, Embase), The Cochrane Library (1997, issue 4), reference lists of articles identified in the previous sources, and additional citations suggested by members of the McMaster research team and partnering organizations. Two reviewers independently rated each article to determine the quality of the methodology used in the study. Studies were included in the evidence-based review if they were randomized, controlled trial (RCTs), involved human subjects, and were published as a full report in a peer-reviewed journal. Studies that included participants with diagnoses other than ADHD (eg, oppositional defiant disorder, conduct disorder) were included in the review only if the study provided a separate analysis for the study participants with ADHD. A problem identified by the review team and associated organizations was the diversity of outcomes used in these many studies. Some studies used indicators or core symptoms of ADHD; others examined aspects of school or social behavior or behaviors at home. This diversity makes clear comparisons among treatment regimens difficult. The McMaster review noted important methodologic limitations in the numerous studies examining interventions for ADHD spanning a period of more than 25 years. Major limitations included small sample sizes and the use of heterogeneous outcome measures. The review found few studies in most of the study areas. Drug-to-Drug Comparisons Twenty-three studies on specific drug-to-drug comparisons were included in the review. These included studies comparing different stimulant medications: 8 studies compared MPH and DEX,9–17 2 compared MPH and PEM,18,19 and 1 compared DEX and PEM.20 Three studies compared a stimulant drug and a tricyclic antidepressant. One study compared MPH and desipramine,21 and 2 compared MPH and imipramine.22,23 Also included were studies comparing different formulations of the same drug. Three studies compared regular and sustainedrelease formulations of MPH,24–26 and 1 study compared different isomers of MPH (l-MPH versus d-MPH).27 Finally, 1 study compared DEX and levoamphetamine.9 The stimulant-stimulant comparisons documented few, if any, differences among MPH, DEX, and PEM. Findings from the 3 review

Pesticides are a broad group of heterogeneous chemicals that have a significant public health benefit by increasing food production productivity and decreasing food-borne and vector-borne diseases. However, depending on the agent and the exposure, they may pose health risks. Because of their behavior, acute accidental toxic exposures occur more commonly in children. Because of the dietary habits and greater intake of foods per kilogram in children and because some infants are breastfed, there is also concern about the effects on them of low-level environmental exposures. In the absence of direct conclusive evidence, consistent and relevant observations have led some investigators to infer that chronic low-dose exposure to certain pesticides might pose a potential hazard to the health and development of infants and children. Other investigators have concluded that such inferences can be neither supported nor refuted at the present time. The pediatrician has a role to play in recognizing the symptoms of acute exposure and to be able to provide appropriate treatment. It is essential to study whether there are subtle neurologic effects that may result from low-level pesticide exposures in individual patients.

Pesticides are a broad group of heterogeneous chemicals that have a significant public health benefit by increasing food production productivity and decreasing food-borne and vector-borne diseases. However, depending on the agent and the exposure, they may pose health risks. Because of their behavior, acute accidental toxic exposures occur more commonly in children. Because of the dietary habits and greater intake of foods per kilogram in children and because some infants are breastfed, there is also concern about the effects on them of low-level environmental exposures. In the absence of direct conclusive evidence, consistent and relevant observations have led some investigators to infer that chronic low-dose exposure to certain pesticides might pose a potential hazard to the health and development of infants and children. Other investigators have concluded that such inferences can be neither supported nor refuted at the present time. The pediatrician has a role to play in recognizing the symptoms of acute exposure and to be able to provide appropriate treatment. It is essential to study whether there are subtle neurologic effects that may result from low-level pesticide exposures in individual patients.

Parents in all countries want and deserve safe and healthy environments for their children. Children in all countries need, as part of normal growth and development, regular and frequent opportunities to interact with their environments as they learn to crawl, run, climb, swim, and explore. Environmental scientists and regulators recognize that environmental hazards are not contained by international borders. This is of special concern for children, because they are intrinsically at greater risk, compared to adults. They have different opportunities for exposure, greater response to certain toxicants, and less empowerment to alter their environments. There is a growing awareness that adverse health effects in children can adversely affect a country's future productivity and well-being. Multiple government agencies, NGOs, and advocates are mobilizing to address these concerns. A sustained concerted effort will be needed to afford equitable and effective environmental health protection to the world's children, present and future.

To identify kidney injury and dysfunction among persons exposed to hazardous substances in the environment, a battery of biomarker tests has been identified for systematic public health use. The standardized use of tests for conducting field epidemiology studies was reviewed in a 1995 joint American-European workshop, and recommended tests were selected by the Agency for Toxic Substances and Disease Registry (ATSDR) and the Centers for Disease Control and Prevention (CDC). These tests would be useful in conducting public health activities but are not recommended in a manner that would suggest changes in routine clinical practice. The tests selected include serum creatinine, urine analysis, urinary albumin, retinol-binding protein, N-acetyl-beta-D-glucosaminidase (NAG), alanine aminopeptidase (AAP), and osmolality. Urinary creatinine was also included to adjust for urine concentration. The tests were chosen for use not only in epidemiologic field studies but also clinically oriented population screening and case studies of persons exposed to hazardous substances at waste sites. Studies using the battery may address the relationship between kidney damage and dysfunction and exposures to hazardous substances, especially in susceptible populations including children. Also, longitudinal studies should be conducted to evaluate the long-term health implications of abnormal tests and to measure the tests' predictive value for renal injury. These studies could evaluate the continuum of renal dysfunction as expressed by persistent decrements in glomerular filtration to the development of end-stage renal disease.

To identify neurotoxic effects in children living near hazardous waste sites, the Agency for Toxic Substances and Disease Registry (ATSDR) has designed a basic Pediatric Environmental Neurobehavioral Test Battery (PENTB) for children 1 through 16 years of age. It emphasizes tests appropriate to the stages of a child's development. These stages were fundamental factors in selecting tests for the PENTB, which includes both informant- and performance-based assessment procedures. Assessment of children under 4 years of age is restricted to four informant-based instruments, to evaluate as many functions as possible while minimizing testing time and the professional expertise needed in the test setting. The assessment of children 4 through 16 years of age includes 10 performance-based tests to evaluate key functions within the cognitive, motor, and sensory domains analogous to functions affected by neurotoxic chemicals in adults. In all age groups, it is crucial to also assess family, cultural, economic, and other potentially confounding variables.

The Agency for Toxic Substances and Disease Registry (ATSDR) has focused its health assessment efforts on seven priority health conditions, including neurotoxic disorders, and has begun to select tests and associated measurement tools that can detect those health effects. The evaluation of community-level exposures has introduced new challenges beyond the earlier testing models based on occupational exposures. Community populations are far more diverse than those found in workplace settings, including children, elderly persons, and the infirm, and the neurotoxic agents present at most hazardous waste sites usually are incompletely characterized and commonly are found in complex mixtures. This article describes the background to the four following articles reporting on a 3-day national workshop convened to assist ATSDR in developing standardized neurobehavioral test batteries for studies of adverse health outcomes in communities.

Nationally recognized experts participated in a 3-day workshop to discuss the complex issues associated with neurobehavioral testing in environmental health settings, and to propose basic and focused test batteries for use in evaluating populations living near hazardous chemical sites. The Adult Environmental Neurobehavioral Test Battery (AENTB), which evaluates major neurobehavioral domains and functions, was adopted by the Agency for Toxic Substances and Disease Registry (ATSDR) for use as a basic screening panel in field studies. Pilot testing of the AENTB demonstrated an examiner training requirement of 3-6 practice sessions, a mean total testing time of 58.0 min (SD = 9.6), and, for 9 of the component tests, a sample size requirement of fewer than 140 (alpha = 0.05, 95% power) to detect a 20% difference between study groups. ATSDR administered the AENTB to 467 persons, selected randomly from 1,382 participants in field study sites in three states. Total testing time varied noticeably by participant age and study site, suggesting an ongoing need for site-specific controls in each field study using the AENTB. Also planned is adoption of a pediatric test battery to evaluate the domains and functions most relevant at major stages of child development.

Communities surrounding the Rocky Mountain Arsenal (RMA), a Superfund site in Colorado, were studied in order to determine whether exposures to arsenic were greater among persons who resided there than among residents of a comparison area. A census was conducted in areas adjacent to the RMA and in a comparison area 12-15 miles distant. From a stratified random sample, 469 persons were interviewed and urine samples obtained. Arsenic was detected in urine from 43 (9.2%) of the 469 persons sampled at a detection limit of 10 ppb. Trace levels of arsenic (detectable, but non-quantifiable) were found in 184 (39.2%) of those persons sampled. Neither the frequency of detection, the arithmetic mean nor the geometric mean values for urine arsenic was found to be statistically different when persons living near the site were compared to persons from the more distant comparison area. Therefore, the data were pooled across the study areas to evaluate risk factors for exposure to arsenic in this population-based sample. Multivariate logistic regression analyses were conducted to evaluate the risk of arsenic exposure associated with variables included in the interviews while controlling for confounding. Pathways for exposure to arsenic were evaluated through analysis of residence history, occupation, hobbies, dietary habits, water supply, housing and activity patterns. Children of Hispanic origin or non-white race, children who drank less than three glasses of water daily, and children who spent more time outdoors had an increased risk of having > or = 10 ppb of arsenic in their urine. Among adults, younger persons, especially those less than 40 years of age, persons of Hispanic origin or nonwhite race, and those employed in occupations where arsenic is likely to be found had an increased risk of having > or = 10 ppb of urine arsenic. Consumption of red wine or fish during the week prior to sampling was associated with trace levels of arsenic in urine.

Communities surrounding the Rocky Mountain Arsenal (RMA), a Superfund site in Colorado, were studied in order to determine whether exposures to mercury were greater among persons who resided there than among residents of a comparison area 12-15 miles distant. From a census-based stratified random sample, 469 persons were interviewed and urine samples were obtained for biomonitoring. Mercury was detected in urine from 32 (6.8%) of the 469 persons sample at a detection limit of 5 ppb. Trace levels of mercury (detectable, but nonquantifiable) were found in 80 (17.1%) of the persons sampled. Neither