BACKGROUND: Experiencing Failure to Thrive or malnutrition in early years has been associated with children later displaying low Intelligence Quotient (IQ). The current study's aim was to examine whether Failure to Thrive in Toddlers with Lack of Interest in Eating and Food, a subtype of Avoidant/Restrictive Food Intake Disorder as defined by DSM-5, which has also previously been identified as Infantile Anorexia (IA), was associated with poor cognitive development outcomes during later childhood. METHODS: The IQs and growth parameter of 30 children (53% female) previously diagnosed and treated for IA at 12 to 42 months of age, were reevaluated at a mean age of 10.0 years (SD = 2.1 years) and compared to 30 matched control children. Children's growth was assessed using Z-scores and their cognitive development was measured using the Wechsler Intelligence Scale for Children-4th Edition. RESULTS: None of the growth parameters were significantly related to IQ. Further, IQ scores of children previously diagnosed with IA and control children were not significantly different. However, the education level of children's fathers had a significantly positive effect on IQ. CONCLUSIONS: Our study highlights the disjunction between growth parameters and IQ within our sample. Overall, our findings suggest that the primary target of intervention for these children should be the parent-child conflict around the feeding relationship, rather than a focus on the child's weight itself. Finally, our results confirm the relevance to include fathers in the intervention of these children.

Many environmental chemicals are being identified as suspected neurotoxicants based on the findings of both experimental and epidemiological studies. Organophosphate esters (OPEs), which are among the chemicals that have replaced neurotoxic polybrominated diphenyl ethers (PBDEs) after 2004, have also become an important public health topic as evidence regarding their potential for early-life neurotoxicity is growing. In 233 mother child pairs from Cincinnati, OH, we measured concentrations of the OPE metabolites bis(1,3-dichloro-2-propyl) phosphate (BDCIPP), bis-2-chloroethyl phosphate (BCEP), diphenyl phosphate (DPHP), and di-n-butyl phosphate (DNBP) in the urine of pregnant women at 16 and 26 weeks gestation and at delivery. At age 8 years, we assessed children's cognition using the Wechsler Intelligence Scale for Children-IV. In models adjusted for maternal race, income, body mass index, and IQ, maternal urinary BCEP was associated with a modest increase in child full-scale IQ (ß: 0.81 per a ln-unit BCEP increase; 95 % CI: 0.00, 1.61) while other OPEs were not associated with changes in full-scale IQ or any IQ subscales. Maternal serum PBDE concentrations did not confound the relationships between urinary OPE metabolites and child IQ. Using Bayesian kernel machine regression, we did not find that concentrations of a mixture of OPE metabolites during gestation was associated with any child cognition measures. The results of this study are not consistent with other published work, and a larger sample size would be beneficial to explore potential associations more fully. Therefore, additional studies are necessary to continue studying prenatal OPE exposure and child neurodevelopment and behavior.

INTRODUCTION: Gestational exposure to chemical mixtures, which is prevalent among pregnant women, may be associated with adverse childhood neurodevelopment. However, few studies have examined relations between gestational chemical mixture exposure and children's cognitive abilities. METHODS: In a cohort of 253 pregnant women and their children from Cincinnati, OH (enrolled 2003-2006), we quantified biomarker concentrations of 43 metals, phthalates, phenols, polybrominated diphenyl ethers, organophosphate and organochlorine pesticides, polychlorinated biphenyls, perfluoroalkyl substances, and environmental tobacco smoke in blood or urine. Using k-means clustering and principal component (PC) analysis, we characterized chemical mixtures among pregnant women. We assessed children's cognitive abilities using the Wechsler Preschool and Primary Scale of Intelligence-III and Wechsler Intelligence Scale for Children-IV at ages 5 and 8 years, respectively. We estimated covariate-adjusted differences in children's cognitive ability scores ]=cross clusters, and with increasing PC scores and individual biomarker concentrations. RESULTS: Geometric mean biomarker concentrations were generally highest, intermediate, and lowest among women in clusters 1, 2, and 3, respectively. Children born to women in clusters 1 and 2 had 5.1 (95% CI:-9.4,-0.8) and 2.0 (95% CI:-5.5, 1,4) lower performance IQ scores compared to children in cluster 3, respectively. PC scores and individual chemical biomarker concentrations were not associated with cognitive abilities. CONCLUSIONS: In this cohort, combined prenatal exposure to phenols, certain phthalates, pesticides, and perfluoroalkyl substances was inversely associated with children's cognition, but some individual chemical biomarker concentrations were not. Additional studies should determine if the aggregate impact of these chemicals on cognition is different from their individual effects.

BACKGROUND: Early-life phthalate exposures may adversely affect children's neurodevelopment by disrupting thyroid function, reducing gonadal hormone levels, or altering fatty acid concentrations in the brain. This study aimed to identify periods of heightened susceptibility during gestation, infancy, and childhood to the impact of phthalates on children's cognitive abilities. METHODS: We used data from 253 mother-child pairs in the Health Outcomes and Measures of the Environment (HOME) Study (Cincinnati, Ohio), a longitudinal pregnancy and birth cohort. We quantified urinary concentrations of 11 phthalate metabolites in samples collected twice during gestation and 6 times during study visits when children were aged 1-8 years using a modified method of on-line solid phase extraction coupled with isotope dilution-high performance liquid chromatography-tandem mass spectrometry. We assessed children's intelligence (IQ) at ages 5 and 8 years using the Wechsler Preschool and Primary Scale of Intelligence-III and Wechsler Intelligence Scale for Children-IV, respectively. We estimated covariate-adjusted associations between a 1-standard deviation increase in log10-transformed urinary phthalate metabolite concentrations at each visit and children's IQ, adjusting for demographic, perinatal, and child factors; we tested for differences in these associations across visits using multiple informant models. RESULTS: Associations between some phthalate metabolites and IQ varied by visit (phthalate x visit interaction p-values<0.20). The sum of di(2-ethylhexyl) phthalate metabolites (SigmaDEHP), mono(3-carboxypropyl) phthalate, and monoethyl phthalate at age 3 years, and monobenzyl phthalate at 16 weeks gestation and child ages 3, 5, and 8 years were inversely associated with children's full-scale IQ. For example, each 1-standard deviation increase in SigmaDEHP at age 3 was associated with a 1.9-point decrease in full-scale IQ (95% confidence interval: -3.7, -0.2). Mono-n-butyl phthalate and mono-isobutyl phthalate at age 4 years were positively associated with children's full-scale IQ. CONCLUSION: Urinary concentrations of several phthalate metabolites at age 3 years, compared to other time periods, were more strongly associated with decreased cognitive abilities in these children.

BACKGROUND: Toxicological studies indicate that poly- and perfluoroalkyl substances (PFAS) may be neurotoxic, but human studies have yet to provide compelling evidence for PFAS' impact on cognitive abilities. OBJECTIVE: To test whether prenatal and childhood PFAS are associated with cognitive abilities at 8 years and whether sex modifies these associations. METHODS: We included 221 mother-child pairs from the Health Outcomes and Measures of the Environment (HOME) Study, a birth cohort in Cincinnati, OH (USA). We quantified PFAS in maternal serum at 16+/-3 weeks gestation and in child serum at 3 and 8 years. We used the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) at age 8 years, assessing Full Scale IQ (FSIQ), verbal comprehension, perceptual reasoning, working memory, and processing speed. We used multiple informant models to estimate covariate-adjusted differences in WISC-IV scores by repeated ln-transformed PFAS. RESULTS: Prenatal and childhood perfluorooctane sulfonate (PFOS) and perfluorohexane sulfonate (PFHxS) were not associated with WISC-IV measures. We observed an increase of 4.1-points (95% CI 0.3, 8.0) and 5.7-points (95% CI 1.2, 10.2) in working memory with 1-ln unit increase in prenatal perfluorooctanoate (PFOA) and perfluorononanoate (PFNA), respectively. In addition, PFNA at 3 years was associated with better FSIQ and perceptual reasoning. Child sex modified the relationship between prenatal PFOA and FSIQ; the association was positive in females only. Sex also modified the association between concurrent PFOS and FSIQ, with males having higher scores. CONCLUSION: We did not observe adverse associations between prenatal and childhood PFAS and cognitive function at age 8 years.

BACKGROUND: Exposure to triclosan, an endocrine disrupting chemical, may affect thyroid hormone homeostasis and adversely affect neurodevelopment. OBJECTIVE: Using a longitudinal pregnancy and birth cohort, we investigated associations between triclosan exposures during different time windows, and cognitive test scores at 8 y of age in 198 children from the HOME Study. METHODS: We quantified triclosan in urine samples from mother-child pairs up to nine times between the second trimester of gestation and 8 y of age. The Wechsler Intelligence Scale for Children-IV [i.e., Full-Scale Intelligence Quotient (IQ)] assessment was administered to HOME Study children at 8 y of age. We estimated covariate-adjusted triclosan-IQ associations at each visit. We also tested whether associations between triclosan concentrations and cognitive test scores varied among exposure at different time periods. RESULTS: Full-Scale IQ was not significantly associated with urinary triclosan concentrations during gestation or childhood but was significantly associated with a 10-fold increase in maternal urinary triclosan concentration at delivery [-4.5 points (95% CI: -7.0, -2.0)]. Perceptual Reasoning Index (PRI) scores were significantly decreased in association with urinary triclosan concentrations at delivery and at 2 y of age. Associations between repeated triclosan concentrations and cognitive test scores significantly varied among exposure at different time periods for Full-Scale IQ, PRI, Verbal Comprehension Index, and Working Memory (triclosan-visit interaction p</=0.04). CONCLUSION: Urinary triclosan concentrations at delivery, but not during mid to late pregnancy and childhood, were associated with significantly lower children's cognitive test scores at 8 y of age in this cohort of U.S. children. https://doi.org/10.1289/EHP2777.

BACKGROUND: Early life BPA exposure could affect neurobehavior, but few studies have investigated whether there are developmental periods when the fetus or child is more vulnerable to these potential effects. OBJECTIVES: We explored windows of vulnerability to BPA exposure in a multiethnic cohort of 228 mothers and their children from Cincinnati, Ohio. METHODS: We measured urinary BPA concentrations at up to two prenatal and six postnatal time points from the 2nd trimester of pregnancy until the child was age 8years. At age 8years, we administered the Behavioral Assessment System for Children-2 (BASC-2), Behavior Rating Inventory of Executive Function, and Wechsler Intelligence Scale for Children-IV. We estimated covariate-adjusted differences in composite scores from each instrument using a multiple informant model designed to identify heightened windows of vulnerability. RESULTS: Among all children, there was not strong evidence that the associations between BPA and neurobehavior varied by the timing of exposure (Visit x BPA p-values≥0.16). However, child sex modified the associations of repeated BPA measures with BASC-2 scores (Visit x Sex x BPA p-values=0.02-0.23). For example, each 10-fold increase in prenatal BPA was associated with more externalizing behaviors in girls (β=6.2, 95% CI: 0.8, 11.6), but not boys (β=-0.8, 95% CI: -5.0, 3.4). In contrast, a 10-fold increase in 8-year BPA was associated with more externalizing behaviors in boys (β=3.9, 95% CI: 0.6, 7.2), but not girls (β=0.3, 95% CI: -3.5, 4.1). CONCLUSIONS: We found that sex-dependent associations between BPA and child neurobehavior may depend on the timing of BPA exposure.

BACKGROUND: Prenatal polybrominated diphenyl ether (PBDE) exposure has been associated with decrements in IQ and increased attention deficit/hyperactivity disorder related behaviors in children; however, data are limited for the role of postnatal exposures. OBJECTIVES: We investigated the association between a series of childhood PBDE concentrations and Full-Scale Intelligence Quotient (FSIQ) and externalizing problems at 8 years. METHODS: We used data from 208 children in the Health Outcomes and Measures of the Environment (HOME) Study, a prospective pregnancy and birth cohort. Child serum PBDEs were measured at 1, 2, 3, 5, and 8 years; missing serum PBDE concentrations were estimated via multiple imputation. The Wechsler Intelligence Scales for Children-IV and the Behavior Assessment System for Children-2 was used to assess intelligence and externalizing behavior, respectively, in children at 8 years. We used multiple informant models to estimate associations between repeated lipid-adjusted PBDEs and child neurobehavior and to test for windows of susceptibility. RESULTS: Postnatal exposure to PBDE congeners (- 28, - 47, - 99, - 100, and - 153) at multiple ages was inversely associated with FSIQ at 8 years. For instance, a 10-fold increase in BDE-153 concentrations at 2, 3, 5, and 8 years were all related to lower FSIQ at age 8 (beta for 3 years: - 7.7-points, 95% CI - 12.5, - 2.9; beta for 8 years: - 5.6-points, 95% CI - 10.8, - 0.4). Multiple PBDE congeners at 8 years were associated with increased hyperactivity and aggressive behaviors at 8 years. CONCLUSIONS: Postnatal PBDE exposure was associated with decrements in FSIQ and increases in hyperactivity and aggressive behaviors.

Prenatal exposure to organophosphate pesticides, which is ubiquitous, may be detrimental to neurological development. We examined 327 mother/infant pairs in Cincinnati, Ohio, between 2003 and 2006 to determine associations between prenatal exposure to organophosphate pesticides and neurodevelopment. Twice during pregnancy urinary concentrations of 6 common dialkylphosphates, nonspecific metabolites of organophosphate pesticides, were measured. Aggregate concentrations of diethylphosphates, dimethylphosphates, and total dialkylphosphates were calculated. Bayley Scales of Infant Development, Second Edition-Mental and Psychomotor Developmental indices were administered at ages 1, 2, and 3 years, the Clinical Evaluation of Language Fundamentals-Preschool, Second Edition, at age 4, and the Wechsler Preschool and Primary Scale of Intelligence, Third Edition, at age 5. Mothers with higher urinary total dialkylphosphate concentrations reported higher levels of socioeconomic status and increased fresh fruit and vegetable intake. We found no associations between prenatal exposure to organophosphate pesticides and cognition at 1-5 years of age. In our cohort, exposure to organophosphate pesticides during pregnancy was not associated with cognition during early childhood. It is possible that a higher socioeconomic status and healthier diet may protect the fetus from potential adverse associations with gestational organophosphate pesticide exposure, or that dietary exposure to the metabolites is innocuous and not an ideal measure of exposure to the parent compound.

BACKGROUND: Prenatal polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs) exposures may influence children's neurodevelopment. OBJECTIVE: To examine the association of prenatal PBDE and PCB exposures with children's reading skills at ages 5 and 8 years, Full-Scale Intelligence Quotient (FSIQ) and Externalizing Problems at age 8 years. METHODS: From 239 mother-child pairs recruited (2003-2006) in Cincinnati, OH, we measured maternal serum PBDE and PCB concentrations, assessed child's reading skills using the Woodcock-Johnson Tests of Achievement III (WJ-III) at age 5 years and the Wide Range Achievement Test-4 (WRAT-4) at age 8 years, tested FSIQ using the Wechsler Intelligence Scale for Children-IV (WISC-IV), and Externalizing Problems using the Behavioral Assessment System for Children-2 (BASC-2) at age 8 years. We used multiple linear regression to examine the association of prenatal PBDE and PCB concentrations and reading, FSIQ and Externalizing Problems after adjustment for covariates. RESULTS: A 10-fold increase in Sum4PBDEs (BDE-47, -99, -100 and -153) was not significantly associated with reading scores at age 5 years at the p=0.05 level, but was inversely associated with Reading Composite scores (beta: -6.2, 95% CI: -11.7, -0.6) and FSIQ (beta: -5.3, 95% CI: -10.6, -0.02) at age 8 years; it was positively associated with Externalizing Problems score (beta: 3.5, 95% CI: -0.1, 7.2) at age 8 years. Prenatal Sum4PCBs (PCB-118, -153, -138-158, and -180) was not significantly associated with child's reading skills, FSIQ and Externalizing Problems. CONCLUSION: Prenatal PBDE concentration was inversely associated with reading skills and FSIQ, positively associated with Externalizing Problems at age 8 years. No significant associations were found in prenatal PCB concentration.

OBJECTIVE: To examine the effects of pre-pregnancy alcohol drinking on child neuropsychological functioning. DESIGN: Prospective follow-up study. SETTING AND POPULATION: 154 women and their children sampled from the Danish National Birth Cohort. METHODS: Participants were sampled based on maternal alcohol consumption before pregnancy. At 5 years of age, the children were tested with the Wechsler Preschool and Primary Scale of Intelligence-Revised, the Test of Everyday Attention for Children at Five (TEACh-5), and the Movement Assessment Battery for Children (MABC). The Behaviour Rating Inventory of Executive Function (BRIEF) was completed by the mothers and a preschool teacher. Parental education, maternal IQ, prenatal maternal smoking, child's age at testing, child's sex, and maternal alcohol intake during pregnancy were considered potential confounders. MAIN OUTCOME MEASURES: Performance on the Wechsler Preschool and Primary Scale of Intelligence-Revised, the TEACh-5, the MABC, and the BRIEF. RESULTS: Intake of 15-21 drinks/week on average prior to pregnancy was not associated with any of the outcomes, but intake of ≥22 drinks/week on average was associated with a significantly lower adjusted mean full scale IQ and lower adjusted means in overall attention and sustained attention score, but not in selective attention score or any of the BRIEF index scores or MABC scores. CONCLUSIONS: Intake of ≥22 drinks/week before pregnancy was associated with lower mean full scale IQ, overall attention and sustained attention. Assessment of pre-pregnancy drinking provides additional information regarding potential prenatal alcohol exposure and its implications for child neurodevelopment.

BACKGROUND: While it is a national priority to support the health and education of students, these sectors must better align, integrate, and collaborate to achieve this priority. This article summarizes the literature on the connection between health and academic achievement using the Whole School, Whole Community, and Whole Child (WSCC) framework as a way to address health-related barriers to learning. METHODS: A literature review was conducted on the association between student health and academic achievement. RESULTS: Most of the evidence examined the association between student health behaviors and academic achievement, with physical activity having the most published studies and consistent findings. The evidence supports the need for school health services by demonstrating the association between chronic conditions and decreased achievement. Safe and positive school environments were associated with improved health behaviors and achievement. Engaging families and community members in schools also had a positive effect on students' health and achievement. CONCLUSIONS: Schools can improve the health and learning of students by supporting opportunities to learn about and practice healthy behaviors, providing school health services, creating safe and positive school environments, and engaging families and community. This evidence supports WSCC as a potential framework for achieving national educational and health goals.

Although banned in most countries, dichlorodiphenyl-trichloroethane (DDT) continues to be used for vector control in some malaria endemic areas. Previous findings from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) cohort study found increased prenatal levels of DDT and its breakdown product dichlorodiphenyl-dichloroethylene (DDE) to be associated with altered neurodevelopment in children at 1 and 2years of age. In this study, we combined the measured maternal DDT/E concentrations during pregnancy obtained for the prospective birth cohort with predicted prenatal DDT and DDE levels estimated for a retrospective birth cohort. Using generalized estimating equation (GEE) and linear regression models, we evaluated the relationship of prenatal maternal DDT and DDE serum concentrations with children's cognition at ages 7 and 10.5years as assessed using the Full Scale Intelligence Quotient (IQ) and 4 subtest scores (Working Memory, Perceptual Reasoning, Verbal Comprehension, and Processing Speed) of the Wechsler Intelligence Scale for Children (WISC). In GEE analyses incorporating both age 7 and 10.5 scores (n=619), we found prenatal DDT and DDE levels were not associated with Full Scale IQ or any of the WISC subscales (p-value>0.05). In linear regression analyses assessing each time point separately, prenatal DDT levels were inversely associated with Processing Speed at age 7years (n=316), but prenatal DDT and DDE levels were not associated with Full Scale IQ or any of the WISC subscales at age 10.5years (n=595). We found evidence for effect modification by sex. In girls, but not boys, prenatal DDE levels were inversely associated with Full Scale IQ and Processing Speed at age 7years. We conclude that prenatal DDT levels may be associated with delayed Processing Speed in children at age 7years and the relationship between prenatal DDE levels and children's cognitive development may be modified by sex, with girls being more adversely affected.

BACKGROUND: Prior research reports inverse associations between maternal prenatal urinary phthalate metabolite concentrations and mental and motor development in preschoolers. No study evaluated whether these associations persist into school age. METHODS: In a follow up of 328 inner-city mothers and their children, we measured prenatal urinary metabolites of di-n-butyl phthalate (DnBP), butylbenzyl phthalate (BBzP), di-isobutyl phthalate (DiBP), di-2-ethylhexyl phthalate and diethyl phthalate in late pregnancy. The Wechsler Intelligence Scale for Children, 4th edition was administered at child age 7 years and evaluates four areas of cognitive function associated with overall intelligence quotient (IQ). RESULTS: Child full-scale IQ was inversely associated with prenatal urinary metabolite concentrations of DnBP and DiBP: b = -2.69 (95% confidence interval [CI] = -4.33, -1.05) and b = -2.69 (95% CI = -4.22, -1.16) per log unit increase. Among children of mothers with the highest versus lowest quartile DnBP and DiBP metabolite concentrations, IQ was 6.7 (95% CI = 1.9, 11.4) and 7.6 (95% CI = 3.2, 12.1) points lower, respectively. Associations were unchanged after control for cognition at age 3 years. Significant inverse associations were also seen between maternal prenatal metabolite concentrations of DnBP and DiBP and child processing speed, perceptual reasoning and working memory; DiBP and child verbal comprehension; and BBzP and child perceptual reasoning. CONCLUSION: Maternal prenatal urinary metabolite concentrations measured in late pregnancy of DnBP and DiBP are associated with deficits in children's intellectual development at age 7 years. Because phthalate exposures are ubiquitous and concentrations seen here within the range previously observed among general populations, results are of public health significance.

Since 1994, the Centers for Disease Control and Prevention (CDC) has been monitoring policies and practices across multiple components of school health through 2 surveillance systems: the School Health Policies and Practices Study (SHPPS), a national survey periodically conducted at the state, district, school, and classroom levels, and the School Health Profiles (Profiles), a system of surveys assessing school health policies and practices in states, large urban school districts, territories, and tribal governments. CDC has encountered several challenges in implementing these systems. In this commentary, we describe the most common challenges encountered and the strategies that CDC has identified to address them. We hope our experiences will be helpful to others interested in monitoring school health policies and practices.

BACKGROUND: Polybrominated diphenyl ethers (PBDEs) are persistent chemicals that were widely used as flame retardants in furniture, carpet padding, car seats and other consumer products over the past three decades. OBJECTIVE: To examine whether in utero exposure to PBDEs is associated with child cognitive function and behavior in a U.S. study sample. METHODS: In a prospective birth cohort, we measured maternal serum concentrations of BDE-47 and other PBDE congeners in 309 women at 16 weeks of gestation during 2003-2006 and followed their children in Cincinnati, Ohio. We measured cognitive and motor abilities using the Bayley Scales of Infant Development-II at ages 1, 2, 3 years; intelligence using the Wechsler Preschool and Primary Scale of Intelligence-III at age 5 years; and children's behaviors using the Behavioral Assessment System for Children-2 annually at ages 2-5 years. We used linear mixed models or Generalized Estimating Equations with adjustment for potential confounders to estimate associations between these outcomes and log10-transformed PBDE concentrations. RESULTS: The geometric mean of BDE-47 in maternal serum (20.1 ng/g lipid) was comparable to U.S. adult national reference values. Prenatal BDE-47 was not significantly associated with Bayley Mental or Psychomotor Development Indices at 1-3 years, but a ten-fold increase in prenatal BDE-47 was associated with a 4.5-point decrease (95% CI: -8.8, -0.1) in Full Scale IQ and a 3.3-point increase (95% CI: 0.3, 6.3) in the hyperactivity score at age 5 years. CONCLUSIONS: Prenatal exposure to PBDEs was associated with lower IQ and higher hyperactivity scores in children.

BACKGROUND AND PURPOSE: Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care. METHODS: The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke-Ready Hospitals (ASRHs). RESULTS: Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities. CONCLUSIONS: ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.

BACKGROUND: School Health Profiles (Profiles) results help states understand how they compare to each other on specific school health policies and practices. The purpose of this study was to develop composite measures of critical Profiles results and use them to rate each state on their overall performance. METHODS: Using data from state Profiles surveys conducted in 2010, the authors examined 12 key practices: 6 related to a healthy school environment and 6 related to health education. States were divided into quartiles based on the percentage of schools in the state that engaged in the practice, and then rank-ordered based on the sum of their quartile scores. RESULTS: Whereas some states have low ranks or high ranks in both sets of practices, others have a relatively low rank in one set but a high rank in the other. States with the lowest overall sums tend to be in the west and midwest, whereas states with the highest sums tend to be in the east. CONCLUSIONS: This study identifies states whose school health policies and practices should be emulated and other states whose policies and practices are in urgent need of improvement.

BACKGROUND: Professional development (PD) and collaboration help ensure the quality of school health education. The purpose of this study was to examine trends in the percentage of lead health education teachers (LHETs) receiving PD on health topics and collaborating with other school staff on health education activities. METHODS: This study analyzed representative data from 41 states participating in School Health Profiles surveys between 2000 and 2010. Logistic regression examined linear trends in the percentage of LHETs who received PD on 12 topics and who collaborated on health education activities. RESULTS: Significant increases in the percentage of LHETs receiving PD on nutrition and physical activity and significant decreases in the percentage of LHETs receiving PD on alcohol- and other drug-use prevention and human immunodeficiency virus prevention were seen. Significant increases in the percentage of LHETs who collaborated with physical education staff and nutrition services staff were seen in 29 and 39 states, respectively. CONCLUSIONS: Although 10-year increases in PD and collaboration in the areas of nutrition and physical activity are encouraging, PD and collaboration in other topic areas still need improvement. These results will help states target more resources toward PD and collaboration in areas where they have been decreasing.

PROBLEM: Priority health-risk behaviors, which are behaviors that contribute to the leading causes of morbidity and mortality among youth and adults, often are established during childhood and adolescence, extend into adulthood, and are interrelated and preventable. REPORTING PERIOD COVERED: September 2010-December 2011. DESCRIPTION OF THE SYSTEM: The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health-risk behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors the prevalence of obesity and asthma. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and large urban school district school-based YRBSs conducted by state and local education and health agencies. This report summarizes results from the 2011 national survey, 43 state surveys, and 21 large urban school district surveys conducted among students in grades 9-12. RESULTS: Results from the 2011 national YRBS indicated that many high school students are engaged in priority health-risk behaviors associated with the leading causes of death among persons aged 10-24 years in the United States. During the 30 days before the survey, 32.8% of high school students nationwide had texted or e-mailed while driving, 38.7% had drunk alcohol, and 23.1% had used marijuana. During the 12 months before the survey, 32.8% of students had been in a physical fight, 20.1% had ever been bullied on school property, and 7.8% had attempted suicide. Many high school students nationwide are engaged in sexual risk behaviors associated with unintended pregnancies and STDs, including HIV infection. Nearly half (47.4%) of students had ever had sexual intercourse, 33.7% had had sexual intercourse during the 3 months before the survey (i.e., currently sexually active), and 15.3% had had sexual intercourse with four or more people during their life. Among currently sexually active students, 60.2% had used a condom during their last sexual intercourse. Results from the 2011 national YRBS also indicate many high school students are engaged in behaviors associated with the leading causes of death among adults aged ≥ 25 years in the United States. During the 30 days before the survey, 18.1% of high school students had smoked cigarettes and 7.7% had used smokeless tobacco. During the 7 days before the survey, 4.8% of high school students had not eaten fruit or drunk 100% fruit juices and 5.7% had not eaten vegetables. Nearly one-third (31.1%) had played video or computer games for 3 or more hours on an average school day. INTERPRETATION: Since 1991, the prevalence of many priority health-risk behaviors among high school students nationwide has decreased. However, many high school students continue to engage in behaviors that place them at risk for the leading causes of morbidity and mortality. Variations were observed in many health-risk behaviors by sex, race/ethnicity, and grade. The prevalence of some health-risk behaviors varied substantially among states and large urban school districts. PUBLIC HEALTH ACTION: YRBS data are used to measure progress toward achieving 20 national health objectives for Healthy People 2020 and one of the 26 leading health indicators; to assess trends in priority health-risk behaviors among high school students; and to evaluate the impact of broad school and community interventions at the national, state, and local levels. More effective school health programs and other policy and programmatic interventions are needed to reduce risk and improve health outcomes among youth.

BACKGROUND: Dichlorodiphenyltrichloroethane (DDT) continues to be used for control of infectious diseases in several countries. In-utero exposure to DDT and dichlorodiphenyldichloroethylene (DDE) has been associated with developmental and cognitive impairment among children. We examined this association in an historical cohort in which the level of exposure was greater than in previous studies. METHODS: The association of in-utero DDT and DDE exposure with infant and child neurodevelopment was examined in 1100 subjects in the Collaborative Perinatal Project, a prospective birth cohort enrolling pregnant women from 12 study centers in the United States from 1959 to 1965. Maternal DDT and DDE concentrations were measured in archived serum specimens. Infant mental and motor development was assessed at age 8 months using the Bayley Scales of Infant Development, and child cognitive development was assessed at age 7 years, using the Wechsler Intelligence Scale for Children. RESULTS: Although levels of DDT and DDE were relatively high in this population (median DDT concentration, 8.9 mcg/L; DDE, 24.5 mcg/L), neither were related to Mental or Psychomotor Development scores on the Bayley Scales nor to Full-Scale Intelligence Quotient at 7 years of age. Categorical analyses showed no evidence of dose- response for either maternal DDT or DDE, and estimates of the association between continuous measures of exposure and neurodevelopment were indistinguishable from 0. CONCLUSIONS: Adverse associations were not observed between maternal serum DDT and DDE concentrations and offspring neurodevelopment at 8 months or 7 years in this cohort.

OBJECTIVE: To conduct a combined analysis of the estimated effects of maternal average weekly alcohol consumption, and any binge drinking, in early to mid pregnancy on general intelligence, attention, and executive function in 5-year-old children. DESIGN: Follow-up study. SETTING: Neuropsychological testing in four Danish cities 2003-2008. POPULATION: A cohort of 1628 women and their children sampled from the Danish National Birth Cohort. METHODS: Participants were sampled based on maternal alcohol consumption during early pregnancy. At age 5 years, the children were tested for general intelligence, attention, and executive function. The three outcomes were analysed together in a multivariate model to obtain joint estimates and P values for the association of alcohol across outcomes. The effects of low to moderate alcohol consumption and binge drinking in early pregnancy were adjusted for a wide range of potential confounding factors. MAIN OUTCOME MEASURES: Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Test of Everyday Attention for Children at Five (TEACh-5), and the Behavior Rating Inventory of Executive Functions (BRIEF) scores. Results Multivariate analyses showed no statistically significant effects arising from average weekly alcohol consumption or any binge drinking, either individually or in combination. These results replicate findings from separate analyses of each outcome variable. CONCLUSIONS: The present study contributes comprehensive methodological and statistical approaches that should be incorporated in future studies of low to moderate alcohol consumption and binge drinking during pregnancy. Furthermore, as no safe level of drinking during pregnancy has been established, the most conservative advice for women is not to drink alcohol during pregnancy. However, the present study suggests that small volumes consumed occasionally may not present serious concern.

OBJECTIVE: To examine the effects of low to moderate maternal alcohol consumption during early pregnancy on children's intelligence (IQ) at age 5 years. DESIGN: Prospective follow-up study. SETTING: Neuropsychological testing in four Danish cities 2003-2008. POPULATION: A cohort of 1628 women and their children sampled from the Danish National Birth Cohort. METHODS: Participants were sampled based on maternal alcohol consumption during pregnancy. At 5 years of age, children were tested with the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R). Parental education, maternal IQ, maternal smoking in pregnancy, the child's age at testing, gender, and tester were considered core confounding factors, whereas the full model also controlled for maternal binge drinking, age, BMI, parity, home environment, postnatal smoking in the home, health status, and indicators for hearing and vision impairments. MAIN OUTCOME MEASURES: The WPPSI-R. RESULTS: No differences in test performance were observed between children whose mothers reported consuming between one and four or between five and eight drinks per week at some point during pregnancy, compared with children of mothers who abstained. For women who reported consuming nine or more drinks per week no differences were observed for mean differences; however, the risks of low full-scale IQ (OR 4.6; 95% CI 1.2-18.2) and low verbal IQ (OR 5.9; 95% CI 1.4-24.9) scores, but not low performance IQ score, were increased. CONCLUSIONS: Maternal consumption of low to moderate quantities of alcohol during pregnancy was not associated with the mean IQ score of preschool children. Despite these findings, acceptable levels of alcohol use during pregnancy have not yet been established, and conservative advice for women continues to be to avoid alcohol use during pregnancy.

PROBLEM: Sexual minority youths are youths who identify themselves as gay or lesbian, bisexual, or unsure of their sexual identity or youths who have only had sexual contact with persons of the same sex or with both sexes. Population-based data on the health-risk behaviors practiced by sexual minority youths are needed at the state and local levels to most effectively monitor and ensure the effectiveness of public health interventions designed to address the needs of this population. REPORTING PERIOD COVERED: January 2001-June 2009. DESCRIPTION OF SYSTEM: The Youth Risk Behavior Surveillance System (YRBSS) monitors priority health-risk behaviors (behaviors that contribute to unintentional injuries, behaviors that contribute to violence, behaviors related to attempted suicide, tobacco use, alcohol use, other drug use, sexual behaviors, dietary behaviors, physical activity and sedentary behaviors, and weight management) and the prevalence of obesity and asthma among youths and young adults. YRBSS includes state and local school-based Youth Risk Behavior Surveys (YRBSs) conducted by state and local education and health agencies. This report summarizes results from YRBSs conducted during 2001-2009 in seven states and six large urban school districts that included questions on sexual identity (i.e., heterosexual, gay or lesbian, bisexual, or unsure), sex of sexual contacts (i.e., same sex only, opposite sex only, or both sexes), or both of these variables. The surveys were conducted among large population-based samples of public school students in grades 9-12. RESULTS: Across the nine sites that assessed sexual identity, the prevalence among gay or lesbian students was higher than the prevalence among heterosexual students for a median of 63.8% of all the risk behaviors measured, and the prevalence among bisexual students was higher than the prevalence among heterosexual students for a median of 76.0% of all the risk behaviors measured. In addition, the prevalence among gay or lesbian students was more likely to be higher than (rather than equal to or lower than) the prevalence among heterosexual students for behaviors in seven of the 10 risk behavior categories (behaviors that contribute to violence, behaviors related to attempted suicide, tobacco use, alcohol use, other drug use, sexual behaviors, and weight management). Similarly, the prevalence among bisexual students was more likely to be higher than (rather than equal to or lower than) the prevalence among heterosexual students for behaviors in eight of the 10 risk behavior categories (behaviors that contribute to unintentional injuries, behaviors that contribute to violence, behaviors related to attempted suicide, tobacco use, alcohol use, other drug use, sexual behaviors, and weight management). Across the 12 sites that assessed sex of sexual contacts, the prevalence among students who had sexual contact with both sexes was higher than the prevalence among students who only had sexual contact with the opposite sex for a median of 71.1% of all the risk behaviors measured, and the prevalence among students who only had sexual contact with the same sex was higher than the prevalence among students who only had sexual contact with the opposite sex for a median of 29.7% of all the risk behaviors measured. Furthermore, the prevalence among students who had sexual contact with both sexes was more likely to be higher than (rather than equal to or lower than) the prevalence among students who only had sexual contact with the opposite sex for behaviors in six of the 10 risk behavior categories (behaviors that contribute to violence, behaviors related to attempted suicide, tobacco use, alcohol use, other drug use, and weight management). The prevalence among students who only had sexual contact with the same sex was more likely to be higher than (rather than equal to or lower than) the prevalence among students who only had sexual contact with the opposite sex for behaviors in two risk behavior categories (behaviors related to attempted suicide and weight management). INTERPRETATIONS: Sexual minority students, particularly gay, lesbian, and bisexual students and students who had sexual contact with both sexes, are more likely to engage in health-risk behaviors than other students. PUBLIC HEALTH ACTION: Effective state and local public health and school health policies and practices should be developed to help reduce the prevalence of health-risk behaviors and improve health outcomes among sexual minority youths. In addition, more state and local surveys designed to monitor health-risk behaviors and selected health outcomes among population-based samples of students in grades 9-12 should include questions on sexual identity and sex of sexual contacts.

BACKGROUND AND PURPOSE: The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience. METHODS: We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices. RESULTS: Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures. CONCLUSIONS: Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

BACKGROUND: People who engage in unprotected sexual intercourse or use injection drugs are at increased risk for HIV infection and sexually transmitted diseases (STDs). Monitoring changes in behaviors over time can provide information about the effectiveness of new policies and programs. PURPOSE: To measure trends in HIV- and STD-related risk behaviors among high school students in the U.S. during 1991-2009. METHODS: Nationally representative data from the 1991-2009 biennial national Youth Risk Behavior Surveys were analyzed to describe trends in HIV- and STD-related risk behaviors. For each cross-sectional national survey, students completed anonymous, self-administered questionnaires assessing risk behavior participation. This study was approved by the CDC IRB, and parental permission was obtained. To assess the significance of time trends for each behavior, logistic regression analyses were conducted that controlled for gender, grade, and race/ethnicity and simultaneously assessed linear and quadratic effects. Data were analyzed in 2010. RESULTS: During 1991-2009, decreases were observed in the percentage of U.S. high school students who ever had sexual intercourse, had multiple sex partners, and who were currently sexually active. The prevalence of condom use increased during 1991-2003 and then leveled off during 2003-2009. However, these changes in risk behaviors were not observed in some gender and racial/ethnic subgroups. CONCLUSIONS: Additional efforts to reduce HIV- and STD-related risk behaviors, particularly among black and Hispanic students, must be implemented to decrease rates of HIV infection and STDs.

PROBLEM: Priority health-risk behaviors, which are behaviors that contribute to the leading causes of morbidity and mortality among youth and adults, often are established during childhood and adolescence, extend into adulthood, and are interrelated and preventable. REPORTING PERIOD COVERED: September 2008- December 2009. DESCRIPTION OF THE SYSTEM: The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health-risk behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors the prevalence of obesity and asthma. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and local school-based YRBSs conducted by state and local education and health agencies. This report summarizes results from the 2009 national survey, 42 state surveys, and 20 local surveys conducted among students in grades 9-12. RESULTS: Results from the 2009 national YRBS indicated that many high school students are engaged in behaviors that increase their likelihood for the leading causes of death among persons aged 10-24 years in the United States. Among high school students nationwide, 9.7% rarely or never wore a seat belt when riding in a car driven by someone else. During the 30 days before the survey, 28.3% of high school students rode in a car or other vehicle driven by someone who had been drinking alcohol, 17.5% had carried a weapon, 41.8% had drunk alcohol, and 20.8% had used marijuana. During the 12 months before the survey, 31.5% of high school students had been in a physical fight and 6.3% had attempted suicide. Substantial morbidity and social problems among youth also result from unintended pregnancies and STDs, including HIV infection. Among high school students nationwide, 34.2% were currently sexually active, 38.9% of currently sexually active students had not used a condom during their last sexual intercourse, and 2.1% of students had ever injected an illegal drug. Results from the 2009 YRBS also indicated that many high school students are engaged in behaviors associated with the leading causes of death among adults aged >or=25 years in the United States. During 2009, 19.5% of high school students smoked cigarettes during the 30 days before the survey. During the 7 days before the survey, 77.7% of high school students had not eaten fruits and vegetables five or more times per day, 29.2% had drunk soda or pop at least one time per day, and 81.6% were not physically active for at least 60 minutes per day on all 7 days. One-third of high school students attended physical education classes daily, and 12.0% were obese. INTERPRETATION: Since 1991, the prevalence of many health-risk behaviors among high school students nationwide has decreased. However, many high school students continue to engage in behaviors that place them at risk for the leading causes of morbidity and mortality. The prevalence of most risk behaviors does not vary substantially among cities and states. PUBLIC HEALTH ACTION: YRBS data are used to measure progress toward achieving 15 national health objectives for Healthy People 2010 and three of the 10 leading health indicators, to assess trends in priority health-risk behaviors among high school students, and to evaluate the impact of broad school and community interventions at the national, state, and local levels. More effective school health programs and other policy and programmatic interventions are needed to reduce risk and improve health outcomes among youth.

During the transition from childhood to adult-hood, adolescents establish patterns of behavior and make lifestyle choices that affect both their current and their future health. Although adolescence is the healthiest period of the life span, it is also the time when many risk-taking behaviors are formed. During adolescence, youth struggle to adopt and main-tain behaviors that will decrease their risk of develop-ing chronic diseases in adulthood, such as eating nutritiously, engaging in physical activity, and choos-ing not to use tobacco. Other serious health and safety issues, such as motor vehicle crashes, violence, sub-stance abuse, and sexually transmitted infections, also adversely affect adolescents and young adults.These health challenges disproportionately affect cer-tain populations. Health disparities are differences in the burden of disease, injury, and violence. Populations that experience health disparities tend to be those that are subject to underlying inequalities related to factors such as poverty, access to health care, and discrimina-tion. In U.S. society, inequalities can be associated with race or ethnicity, gender, education or income, disabil-ity, geographic location (e.g., rural or urban), or sexual orientation. For example, African American and Hispanic teens are at increased risk for Type 2 diabetes; female adolescents are at increased risk for insufficient phys-ical activity; low-income youth are at increased risk for early initiation of sexual activity; youth with dis-abilities are at greater risk for attempted suicide; rural adolescents are more likely to smoke; and lesbian, gay, and bisexual youth are at greater risk for experiencing violence

BACKGROUND AND OBJECTIVE: School-based BMI measurement has attracted attention across the nation as a potential approach to address obesity among youth. However, little is known about its impact or effectiveness in changing obesity rates or related physical activity and dietary behaviors that influence obesity. This article describes current BMI-measurement programs and practices, research, and expert recommendations and provides guidance on implementing such an approach. METHODS: An extensive search for scientific articles, position statements, and current state legislation related to BMI-measurement programs was conducted. A literature and policy review was written and presented to a panel of experts. This panel, comprising experts in public health, education, school counseling, school medical care, and parenting, reviewed and provided expertise on this article. RESULTS: School-based BMI-measurement programs are conducted for surveillance or screening purposes. Thirteen states are implementing school-based BMI-measurement programs as required by legislation. Few studies exist that assess the utility of these programs in preventing increases in obesity or the effects these programs may have on weight-related knowledge, attitudes, and behaviors of youth and their families. Typically, expert organizations support school-based BMI surveillance; however, controversy exists over screening. BMI screening does not currently meet all of the American Academy of Pediatrics' criteria for determining whether screening for specific health conditions should be implemented in schools. CONCLUSION: Schools initiating BMI-measurement programs should adhere to safeguards to minimize potential harms and maximize benefits, establish a safe and supportive environment for students of all body sizes, and implement science-based strategies to promote physical activity and healthy eating.