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abstract ABBREVIATIONS
DAP dialkyl phosphate
DMAP dimethyl alkylphosphate
OBJECTIVE: The goal was to examine the association between urinary
DEAP diethyl alkylphosphate
concentrations of dialkyl phosphate metabolites of organophosphates OR odds ratio
and attention-decit/hyperactivity disorder (ADHD) in children 8 to 15 CI condence interval
years of age. ADHDattention-decit/hyperactivity disorder
NHANESNational Health and Nutrition Examination Survey
METHODS: Cross-sectional data from the National Health and Nutrition DISC-IVDiagnostic Interview Schedule for Children IV
Examination Survey (2000 2004) were available for 1139 children, who PIRpoverty/income ratio
DSM-IVDiagnostic and Statistical Manual of Mental Disorders,
were representative of the general US population. A structured inter- 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 modied 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,
and approval of the manuscript.
RESULTS: One hundred nineteen children met the diagnostic criteria
www.pediatrics.org/cgi/doi/10.1542/peds.2009-3058
for ADHD. Children with higher urinary dialkyl phosphate concentra-
doi:10.1542/peds.2009-3058
tions, especially dimethyl alkylphosphate (DMAP) concentrations, were
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% con- Address correspondence to Maryse F. Bouchard, PhD, University
of Montreal, Department of Environmental and Occupational
dence interval: 1.14 2.10), with adjustment for gender, age, race/eth- Health, CP 6128 Succursale Centre-Ville, Montreal, QC H3C 3J7,
nicity, poverty/income ratio, fasting duration, and urinary creatinine Canada. E-mail: maryse.bouchard@umontreal.ca
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% condence interval: 1.233.02]), compared with chil- no nancial relationships relevant to this article to disclose.
dren with undetectable levels. Funded by the National Institutes of Health (NIH).
CONCLUSIONS: These ndings 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:e1270e1277
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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
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 2500 g (n 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 20
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-decit/ with missing data were excluded (pov-
mon, but the major source of exposure hyperactivity disorder (ADHD) preva- erty/income ratio [PIR], n 43; fasting
to pesticides for infants and children lence in children 8 to 15 years of age. duration, n 38; urinary creatinine
would be the diet, according to the level, n 1).
National Academy of Sciences.3 The METHODS
US Pesticide Data Programs 2008 Re- Study Design and Population ADHD Assessment
port indicates that detectable concen- The Diagnostic Interview Schedule for
The National Health and Nutrition Ex-
trations of the organophosphate mala- Children IV (DISC-IV), a structured diag-
amination Survey (NHANES) is a
thion were found in 28% of frozen nostic interview designed for use in ep-
population-based, health survey of
blueberry samples, 25% of strawberry idemiological studies,18 was used to
noninstitutionalized US residents con-
samples, and 19% of celery samples.4 assess the presence of ADHD on the
ducted by the National Center for
Children are generally considered to Health Statistics of the Centers for Dis- basis of slightly modied 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
brain is more susceptible to neurotoxi- probability sampling design, with over- (DSM-IV).19 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-
age groups in the US population.6 Chil- 2000 2004, years for which ADHD was lidity,18 reliability for both its English18
dren have reduced expression of de- assessed in children 8 to 15 years of and Spanish20,21 versions, and success-
toxifying enzymes, which contributes age; diagnoses were available for 3998 ful use via telephone in DSM-IV eld tri-
to their vulnerability.7,8 Epidemiologi- children. Urinary DAP metabolite levels als.22 The use of DISC-IV data is re-
cal studies linking exposure to organo- were measured for a random sub- stricted for condentiality 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 problems, poorer short-term stitutional review board, and all par- presence, during the previous 12
memory and motor skills, and longer ticipants provided written informed months, of symptoms related to inat-
reaction times in children.1315 consent. tention, hyperactivity, and impulsivity,
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TABLE 1 Concentrations of Urinary DAP Metabolites (N 1139) tection limit were between 35.7% and
N Below Detection Urinary Metabolite Level, nmol/L 80.0%, depending on the metabolite
Limit, n (%) (Table 1). Most children (93.8%) had
Geometric Interquartile
Mean Range Minimum Maximum 1 detectable metabolite, of the 6
Diethyl phosphate 1133 534 (46.9) 4.7 0.928.1 0.4 5902 DAPs measured. In a multivariate anal-
Diethyl thiophosphate 1121 487 (42.8) 2.0 0.47.6 0.3 650
Diethyl dithiophosphate 1139 911 (80.0) 0.5 0.30.3 0.2 36
ysis, higher DAP concentrations were
Dimethyl phosphate 1139 581 (51.0) 10.7 2.839.0 2.8 1324 associated with higher creatinine con-
Dimethyl thiophosphate 1139 407 (35.7) 13.7 1.958.8 0.9 9929 centrations (P .001), younger age
Dimethyl dithiophosphate 1133 664 (58.3) 1.7 0.47.3 0.3 7006 (P .03), lower blood lead concentra-
DEAPs 1139 253 (22.2) 11.0 2.135.0 0.8 5905
DMAPs 1139 209 (18.3) 41.3 10.1130.7 4.5 10 068 tions (P .06), and higher PIR (P
Total DAPs 1139 71 (6.2) 68.3 24.4186.0 6.0 10 195 .10). DAP concentrations were higher
for children examined in 20032004
(adjusted mean: 18.15 nmol/L; SE: 1.15
DAP metabolite levels were below the teristics similar to those of children
nmol/L), compared with those exam-
analytical limit of detection for a large not included in the sample (Table 2).
ined in 2000 (mean: 12.62 nmol/L; SE:
proportion of children (Table 1), which One hundred nineteen children met
1.24 nmol/L) and 20012002 (mean:
might bias effect estimates,27 we the diagnostic criteria for any ADHD
11.69 nmol/L; SE: 1.18 nmol/L), al-
conducted further analyses on the subtype, which corresponds to a pop-
though not signicantly (P .10). Gen-
metabolite with the highest detection ulation prevalence of 12.1% (95% CI:
der, race/ethnicity, and fasting dura-
frequency, namely, dimethyl thiophos- 9.6%15.1%). The prevalence esti-
tion were not signicantly associated
phate. Cases were categorized as be- mates were 7.6% (95% CI: 5.5%10.4%)
with DAP metabolite concentrations
low the limit of detection or lower or for inattentive subtype, 1.5% (95% CI:
(all P .3).
higher than the median of detectable 0.8%2.7%) for hyperactive/impulsive
concentrations adjusted for creatinine subtype, and 3.0% (95% CI: 2.1% 4.3%) Any Subtype of ADHD
levels. for combined subtype. When children
The odds of meeting the DISC-IV crite-
taking ADHD medication were included
RESULTS ria for ADHD increased with the uri-
as case subjects, there were 148 nary concentrations of total DAP me-
Descriptive Statistics cases. tabolites (Table 3). Adjustment for
Our study sample included 1139 chil- The proportions of children with uri- covariates attenuated the estimates
dren 8 to 15 years of age, with charac- nary DAP concentrations below the de- (for a 10-fold increase in total DAP con-
centration, unadjusted OR: 1.31 [95%
TABLE 2 Comparison of Characteristics of Children 8 to 15 Years of Age Not Included and Included CI: 1.06 1.63]; adjusted OR: 1.21 [95%
in Study Sample CI: 0.971.51]). This association was
Not Included Included
driven by DMAP metabolites, for which
Male, n (%) a 2247 (51.2) (N 4578) 570 (53.2) (N 1139)
the association was statistically signif-
Race/ethnicity, n (%)a
Non-Hispanic white 1138 (59.6) (N 4578) 325 (63.3) (N 1139) icant even after adjustment (OR: 1.55
Black 1533 (16.0) (N 4578) 342 (13.2) (N 1139) [95% CI: 1.14 2.10]). When children
Mexican American 1555 (11.7) (N 4578) 382 (11.6) (N 1139) taking ADHD medication were included
Other/multiracial 352 (12.7) (N 4578) 90 (12.0) (N 1139)
PIR, n (%)a as case subjects, slightly higher effect
1.0 1390 (23.4) (N 4145) 363 (21.4) (N 1139) estimates were obtained for DMAPs
1.01.84 1009 (20.7) (N 4145) 274 (21.3) (N 1139) (adjusted OR: 1.72 [95% CI: 1.312.28]).
1.853.0 730 (20.6) (N 4145) 214 (21.6) (N 1139)
3.0 1016 (35.3) (N 4145) 288 (35.8) (N 1139)
A 10-fold difference in DMAP concen-
Maternal smoking during pregnancy, n (%)a 697 (19.8) (N 4509) 152 (17.7) (N 1125) trations corresponds approximately to
ADHD, n (%)a the increase from the 25th to 75th per-
Any subtype 295 (12.2) (N 2859) 119 (12.1) (N 1139)
centile of childrens concentrations
Inattentive subtype 133 (5.9) (N 2865) 69 (7.6) (N 1139)
Hyperactive subtype 81 (3.2) (N 2860) 21 (1.5) (N 1139) (Table 1). DEAP metabolite levels were
Combined subtype 81 (3.1) (N 2865) 29 (3.0) (N 1139) not signicantly associated with the
Age, weighted mean SE, mo 144 0.6 (N 4578) 143 1.0 (N 1139) odds of ADHD, whether cases were de-
BMI, weighted mean SE, kg/m2 20.8 0.1 (N 4502) 20.6 0.2 (N 1139)
Blood lead level, weighted mean SE, g/dL 1.4 0.04 (N 4036) 1.4 0.04 (N 1093) ned strictly according to the DISC-IV
Maternal age at birth, weighted mean SE, y 26.3 0.2 (N 4432) 26.4 0.3 (N 1107) criteria or included children taking
a Proportions were weighted. ADHD medication (Table 3).
TABLE 5 ORs for Subtypes of ADHD for 10-Fold Increases in Urinary DAP Metabolite Levels (N 1139)
OR (95% CI)
Hyperactive/Impulsive Subtype (n 21) Inattentive Subtype (n 69) Combined Subtype (n 29)
Unadjusted Adjusteda Unadjusted Adjusteda Unadjusted Adjusteda
DEAPs 2.29 (1.254.21) 2.15 (1.064.40) 0.77 (0.521.14) 0.70 (0.491.01) 1.29 (0.682.43) 1.22 (0.592.50)
DMAPs 2.26 (1.333.86) 2.13 (1.084.20) 1.61 (1.102.37) 1.47 (0.992.19) 1.30 (0.562.99) 1.30 (0.483.48)
Total DAPs 1.95 (1.183.22) 1.85 (1.043.27) 1.26 (0.911.75) 1.14 (0.811.61) 1.09 (0.592.01) 1.05 (0.512.16)
a Adjusted for gender, age, race/ethnicity, PIR, fasting duration, and logarithmically transformed urinary creatinine concentration.
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The odds of inattentive subtype in- surements of urinary metabolites of ADHD as were those with undetectable
creased with higher concentrations of organophosphates over a longer time concentrations.
DMAP metabolites (adjusted OR: 1.47 period would provide a better assess- The present study uses a larger sam-
[95% CI: 0.99 2.19]), although this did ment of average exposure, but the ple size than previous investigations
not reach the level of signicance. Con- NHANES does not include longitudinal on neurodevelopmental effects of or-
centrations of DAP metabolites were follow-up assessments. For organo- ganophosphate exposure, as well as
not signicantly associated with the phosphates coming from the diet, the DSM-IV based diagnostic outcomes.
odds of combined subtype. measurement of organophosphate Comparisons across studies are
metabolites in a single urine sample difcult because of differences in
DISCUSSION may reect average exposure levels exposure levels, timing of exposure,
We report an association between uri- reasonably well, to the extent that diet outcomes assessed, and age at as-
nary DMAP metabolite concentrations, is consistent. Given that organophos- sessment. Higher blood chlorpyrifos
which are indicators of exposure to phates are eliminated from the body concentrations during pregnancy
dimethyl-containing organophosphate after 3 to 6 days,28 the detection of were found to be associated with
pesticides, and increased odds of DAPs in the urine of most children in- poorer mental and motor development
ADHD for children 8 to 15 years of age. dicates continuing exposure. An addi- at 3 years,11 and greater postnatal ex-
There was a 55% to 72% increase in the tional consideration is that urinary posure to organophosphates was as-
odds of ADHD for a 10-fold increase in DAP levels might reect not only expo- sociated with difculties with memory,
DMAP concentration, depending on the sure to organophosphates but also attention, motor tasks, behavior,14 and
criteria used for case identication. direct exposure to DAPs present in reaction time.13 Prenatal exposure to
This association was not explained by the environment, resulting from organophosphates also was associ-
gender, age, PIR, race/ethnicity, fast- degradation of organophosphates ated with poorer mental development
ing duration, or creatinine concentra- through hydrolysis or photolysis. at 2 years of age and, as in our study,
tion. Whether DAP metabolite concen- Signicant amounts of DAPs have the association was with DMAP rather
trations are more strongly associated been found on several types of fruits than DEAP metabolites.12 The stronger
with a specic subtype of ADHD is un- and vegetables.29 In any case, mis- association with DMAP metabolites
clear, because of the small numbers of classication of exposure on the ba- could be explained by greater expo-
cases, although the association was sis of measurements of urinary DAP sure to organophosphates metabo-
stronger for the predominantly hyper- levels should be nondifferential and lized into DMAP metabolites, or it might
active/impulsive subtype. This study should bias effect estimates toward indicate greater toxicity of these
should be generalizable to the US pop- the null. organophosphates.
ulation because the NHANES sample is Given the cross-sectional nature of our Several biological mechanisms might
nationally representative, unlike previ- analysis, we cannot rule out the possi- underlie an association between or-
ous studies of groups with higher ex- bility that children with ADHD engage ganophosphate pesticides and ADHD. A
posure levels.1115 With respect to the in behaviors that expose them to primary action of organophosphates,
importance of these ndings, organo- higher levels of organophosphates. If particularly with respect to acute poi-
phosphates are among the most this were the case, however, we would soning, is inhibition of acetylcholinest-
widely used pesticides, and the con- have expected to see higher levels of erase,30 and disruptions in cholinergic
centrations of DAP metabolites among urinary DEAP metabolites as well, signaling are thought to occur in
children did not decrease from 2000 to which was not the case. Another limi- ADHD.31 At doses lower than those
20032004. tation is measurement error, in that needed to inhibit acetylcholinesterase,
The most important limitation of the the concentrations of individual DMAP certain organophosphates affect
present study is the assessment of or- metabolites were below the analytical different neurochemical targets, in-
ganophosphate exposure through limit of detection for large proportions cluding growth factors, several neuro-
measurement of DAP metabolites in of children. This problem, however, transmitter systems, and second-
only 1 spot urine sample. Given that does not apply to the analysis showing messenger systems.32,33 Exposure to
long-term exposure to organophos- that children with levels higher than some of these organophosphate com-
phates likely would be necessary to the median of detectable dimethyl thio- pounds was shown to cause hyperac-
produce neurochemical changes caus- phosphate concentrations were twice tivity and cognitive decits in animal
ing ADHD-like behaviors, serial mea- as likely to be diagnosed as having studies.34,35 Developmental exposure to
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