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01.A Mixed-methods Assessment of Health Care Service Access and Delivery to Youth with Special Health Care needs Attending Exceptional Student Education Schools in Duval County, Florida (p. 421-434)
02.Co-occurrence of Depression and Addiction: An Analysis of Prevalence and Strategies to Target such Populations (p. 413-419)
03.Development of a Measure of Preconception Pregnancy Readiness (p. 379-387)
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Editorial - Vulnerable Children: Break the Cycle of Environmental Health Disparities (p. 357-363) $0.00
Authors:  I. Leslie Rubin, Kelly Ace, Janice Nodvin, Robert J. Geller, Michele Marcus and Joav Merrick

On September 8, 2009 the Southeast Pediatric Environmental Health Specialty Unit (SE PEHSU) at Emory University convened the 4th Annual Break the Cycle symposium in the Rollins School of Public Health at Emory University. The conference showcased several student research projects focusing on environmental health disparities of children who are vulnerable as a result of adverse social and economic factors.
The university students who participated in this program addressed a wide a variety of topics from toxic environmental factors affecting onset of puberty in girls, through exploration of maternal depression and substance abuse, to challenges in special education, the demographics of the built environment and attitudes to organic food among university students.
The designs and methodologies vary significantly and reflect a diversity of styles and disciplines. All underscore the need for further environmental health disparity research that can be used to inform public policy, public health initiatives, and the training of environmental health leaders in a wide range of academic and professional disciplines.
The goal of the Break the Cycle projects is to inspire the students to examine issues of environmental health disparities and to stimulate them to engage the topic as significant factor in their careers, and to provide them with the fundamentals of research and promote a sense of their responsibility as future leaders in our society. In this monograph we also wish to introduce the students’ work to a wider audience, raise interest in children’s environmental health, and encourage additional research in children’s environmental health disparities.

Environmental influences on child health

A myriad of environmental factors interact in complex ways to affect children’s health and wellbeing. Adverse environmental factors can cause, exacerbate, or complicate serious childhood health problems such as asthma, obesity, high blood pressure, diabetes, asthma and neurodevelopmental conditions, such as learning disabilities and attention-deficit-hyperactivity disorder. Unfortunately, many of these environmental factors that operate through direct and indirect mechanisms are not clearly understood. We need to understand this better if we are to help children live longer, healthier, happier and successful lives (1-3).
Efforts to promote children’s health and reduce or eliminate childhood health problems must incorporate an understanding, not only of the how the chemical toxins cause damage to organ systems, but also how physical spaces and structures influence the health, growth and development of children. Home and school environments, open spaces, and community infrastructure help shape children’s diets and influence levels of physical activity.
They also influence children’s interactions with other people and with the natural world around them. The condition, design, and location of homes and schools also have a significant impact the exposure of children to chemical, physical and social hazards. Awareness of these factors can serve to improve the health of children by the proper design, maintenance, and management of neighborhoods, buildings and others spaces that children inhabit and frequent (4).
Disease prevention and health promotion activities targeting children must also reflect the realities of their physiology and their behavior. For example, activities focusing on toxicant exposure must recognize the fact that children are especially vulnerable to environmental toxicants. Compared with adults, children absorb more environmental toxins through the skin because of their greater surface-area-to-body-mass ratio. Their larger air intake relative to body size and closer proximity to the ground increase their vulnerability to air pollutants such as car exhaust. They have a greater tendency to touch and ingest potentially toxic objects they find in their environment. Because of their faster growth and a higher metabolic rate, they are more likely to incorporate such toxins into their maturing organ systems and suffer health consequences some of which may only become evident much later in life. Also, because they are shorter and closer to the ground and play on the ground, they are more likely to come into contact with heavier particulates that may be toxic. It is only necessary to visualize a child walking down a sidewalk to realize that they are breathing air at the level of motorcar exhaust pipes.
For all these reasons, children require special attention and cannot be treated as if they are simply small adults.
Effective child health and wellness promotion also requires a realistic assessment of psychosocial, political, cultural, and economic factors that impact children’s access to healthcare and other resources. Children who grow up in circumstances of social and economic disadvantage are especially likely to experience health problems because of where they live, learn, and play. They are also less likely to have their healthcare and educational needs met. As a result, they are prone to become trapped in a multi-generational cycle of environmental health disparities that interferes with their ability to reach their full potential.

PEHSU Network

Assessing and responding to children’s environmental health concerns requires specialized, multidisciplinary expertise. Recognizing this, the Agency for Toxic Substances and Disease Registry (ATSDR) and the United States Environmental Protection Agency (EPA) established the Pediatric Environmental Health Specialty Units (PEHSU) Program in 1998. Administered by the Association of Occupational and Environmental Clinics (AOEC), this program is comprised of 12 university-based medical teams in the United States, Canada, and Mexico that provide consultation, education, and professional training related to children’s environmental health (5) (see figure 1).
The PEHSUs help ensure that children, families, healthcare professionals, schools, and communities have access to resources and quality information about natural or human-made environmental hazards that adversely affect children’s health and development.

Region IV PEHSU at Emory University

The Southeast (SE) PEHSU was established at Emory University in the year 2000 to serve children, families, healthcare providers and communities throughout Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee. Since then, it has advanced its network and impact through affiliations with Morehouse School of Medicine, the Institute for the Study of Disadvantage and Disability (ISDD), and various community groups.
(websites: and
The primary goals of the SE PEHSU are: 1) improving the health of children with respect to environmental exposures and 2) informing families, communities, and health care providers about environmental hazards, their effects, and practical ways to protect children's health. To that end, the SE PEHSU:

• Provides consultation and technical assistance to agencies, healthcare providers, and concerned members of the community
• Provides direct pediatric environmental healthcare services, including those offered through toxicology, developmental, and asthma clinics
• Refers children with complex needs for appropriate evaluation and treatment
• Conducts environmental health education activities
• Nurtures students in Environmental Health, Pediatrics, Nursing and other academic and professional disciplines
• Supports and participates in research related to children’s environmental health concerns
• Develops relevant educational materials

The SE PEHSU core team is comprised of specialists in medical toxicology, developmental disabilities, environmental epidemiology, nursing and education. Since its founding, it has established itself as a center for pediatric environmental health services, professional education, and research. Its accomplishments include:

• Providing training to more than 2,600 professionals representing a variety of disciplines, including medicine, nursing, public health, law, psychology, and education
• Participating in approximately 60 local, state, and national conferences
• Joining the Southeast Diesel Collaborative, which works to improve air quality by promoting strategies to reduce diesel emissions
• Contributing to the ground-breaking Clinical Recommendations Regarding Return of Children to Areas Impacted by Flooding and/or Hurricanes, which were endorsed by the American Academy of Pediatrics (AAP) and distributed to all pediatricians practicing in areas impacted by Hurricane Katrina
• Collaborating with colleagues in Santiago, Chile on the development of a replicable international PEHSU model
• Receiving the 2005 Children’s Environmental Health Excellence Award from the EPA for work on Vision 2020, a community-based project based in Anniston, Alabama to address the health and developmental problems of children from communities contaminated by lead and polychlorinated biphenyls (PCBs) (6).
• Developing and editing Safe and Healthy School Environments, the first comprehensive text addressing school environmental health issues and concerns (7).

The cycle of environmental health disparities model

Nurturing and resource-rich environments promote optimal health and development for children. Unfortunately, children living in circumstances of social and economic disadvantage often lack adequate care and nurturing. Instead, they tend to live in unsafe and unsupportive environments that place them at increased risk for poor health, developmental delays, impaired learning, and other difficulties that reduce their overall quality of life and limit opportunities for success in adulthood (8-10).
The experiences of the SE PEHSU working on the Vision 2020 project in Anniston, Alabama underscored the importance of adopting a comprehensive approach to children’s environmental health that includes recognition of how environmental health disparities are shaped by social and economic factors and perpetuated over time (11). Understanding the complexities of the environmental factors involved was further heightened after the ISDD launched a project in 2005 to promote research and information dissemination related to health disparities experienced by children and families living in circumstances of social and economic disadvantage. The project, known as Break the Cycle of Disadvantage and Disability, introduced a holistic model that explained how various social, psychological, and physical factors compounded the challenges faced by individuals with limited resources. It also emphasized the importance of interrupting the cycle of disadvantage and disability that perpetuates such difficulties, both over the course of a lifetime and across generations (12).
This model helped the SE PEHSU team better identify factors that must be considered, when promoting children’s environmental health. Moreover, ISDD’s Break the Cycle project helped the PESHU realize that promoting children’s environmental health requires more than the simple recognition of the direct effect of a toxin on the health, growth and development of children. To be effective, it is important to recognize the environment in which the children are more likely to be exposed to the toxins and the populations of children who are particularly vulnerable. These realizations led to the development a conceptual model of the Cycle of Environmental Health Disparities (see figure 2).
As the model illustrates, children living in families headed by adults with limited education and health literacy, limited income and employment opportunities, and a relative lack of power within their community are at increased risk for experiencing adverse environmental health outcomes. Their experience of social and economic disadvantage often leaves them with few housing options in rural, urban, or suburban communities. They are more likely to live in poorly-maintained older homes and be exposed to indoor toxicants, such as lead paint and mold, as well as other outdoor environmental hazards. They are also more likely to live in communities with limited access to transportation, grocery stores, green space, and recreational opportunities. Moreover, they are more likely to be exposed to violence within their immediate community.

Figure 2. Cycle of environmental health disparities.

The increased risk of toxicant exposure, poor nutrition, limited physical activity, abuse, neglect, and stress that are often shaped or exacerbated by environmental conditions, in turn increase children’s risk of physical health problems, such as asthma, obesity, hypertension and neurodevelopmental disorders. They may also interact in a complex manner that contributes to and compounds learning disabilities, ADHD, depression, trauma reactions, substance abuse, and behavioral disorders. A lack of access to comprehensive healthcare and appropriate educational services, as well as discrimination, social stigma, and lack of social capital further increase the likelihood that these children will continue to experience adverse health outcomes, even into adulthood.

Break the cycle of environmental health disparities project

The SE PEHSU Break the Cycle Project is a collaborative, interdisciplinary pediatric environmental health research and training program that encourages university students supervised by academic mentors to conduct research related to the reduction or prevention of environment-related illness and disability in children living in circumstances of social and economic disadvantage. Break the Cycle is designed to:

• Inspire students from a variety of academic disciplines to explore the relationship between the environment and children’s health, as well as develop strategies for addressing identified pediatric environmental health challenges
• Promote collaboration among academic leaders at major universities to facilitate creative examination of the issues relating to the impact of environmental factors on children’s health and quality of life
• Promote the incorporation of children’s environmental health topics into university curricula
• Develop the academic and leadership capacity of professionals within academic and healthcare communities who can, in turn, promote interest in children’s environmental health and environmental justice
• Cultivate future leaders and advocates in our societies


Students and faculty mentors are recruited from universities throughout the Southeast region. Proposed projects are reviewed for relevance, design, and fit within the project cycle by a committee comprised of the core PEHSU team, representative university faculty, environmental health experts, and students. During the research phase, monthly conference calls are held to track the students’ progress and ensure that students and mentors receive sufficient guidance and support.
At the end of each project period, the student researchers are required to present their findings at a symposium sponsored by SE PEHSU and its strategic partners. This symposium not only provides budding scientists, academics and advocates with an opportunity to hone their research presentation skills, but also allows for dissemination of their findings to other scientists and academics as well as healthcare providers, fellow students, advocates and the general public. Each symposium features a nationally-recognized keynote speaker selected for their ability to inspire participants and facilitate relevant discussion. At the conclusion of each project cycle, the symposium’s proceedings are published here in this monograph.


Children living in circumstances of social and economic disadvantage are at high risk for experiencing health problems caused or exacerbated by environmental factors. They are not only vulnerable to adverse chemical and physical factors in their environment, but often become trapped in the cycle of environmental health disparities due to low parental health literacy, limited social capital, and a lack of access to comprehensive healthcare and appropriate educational services. They will only be able to escape that cycle when children’s environmental health becomes a priority and the resources, energy and creativity are amassed and allocated to address environmental health concerns. Such investment may seem unlikely, given the current economic realities. However, not investing in children’s environmental health will prove costlier in the long run.
SE PEHSU has demonstrated that Break the Cycle is a sustainable, cost-effective catalyst for increasing academic interest and advocacy in issues relating to promotion of children’s environmental health. The emphasis of the Break the Cycle project is on recruiting graduate and undergraduate students to become aware of environmental health disparities and cultivate their intellect, interest and creativity to focus on a single project that will make a difference. This encourages the incorporation of information about environmental health issues and environmental health disparities into college curricula. It also encourages students and faculty to embrace a broader, more holistic understanding of children’s environmental health and environmental justice. Additionally, Break the Cycle affords academic mentors who are committed to issues of environmental justice with an the opportunity to inform, guide, and inspire the next generation of professionals who will face the challenge of finding creative solutions to environmental health dilemmas towards assuring safe and healthy environments for all children to grow and develop to their full potential.


This publication was supported by the cooperative agreement award number 1U61TS000118-01 from the Agency for Toxic Substances and Disease Registry (ATSDR). Its contents are the responsibility of the authors and do not necessarily represent the official views of the Agency for Toxic Substances and Disease Registry.

The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing funds to ATSDR under Inter-Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications. 

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Editorial - Vulnerable Children: Break the Cycle of Environmental Health Disparities (p. 357-363)