Dr. Feder: Air pollution is a leading cause of health problems globally, and it is also linked to psychiatric problems in children and adolescents. We’ll take a closer look at the evidence and clinical implications in this episode. Welcome to The Carlat Psychiatry Podcast. This is a special episode from the child psychiatry team.  I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice. 

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. I’m also a regional director at Real Connections Child Development Institute.

Dr. Feder: While many of us have seen articles linking tobacco smoke to ADHD, most of us have not been thinking about air pollution as a relevant clinical factor. 

Mara: There’s a connection between Asthma and mental health, so it makes sense that air pollution would have a negative impact on our patients. 

Dr. Feder: It makes a lot of sense, and I kind of felt like a light bulb went off when this evidence first came to my attention. It was Steve Doraff, an engineer, who got me interested in air pollution in the first place. Steve is developing sensors to use in real estate and other kinds of applications. But wouldn’t you like to know if the home you’re looking might be near a lot of air pollution. Steve tell us more about it. 

Steve: It started in 2017 when I met an associate professor from Tufts at a building construction conference where he had presented on the ill effects of indoor air pollution. Our initial conversations resulted in a project associating health risks to the exposure to loud noise exposure where I developed a wearable device capturing, analyzing and pushing noise information to the cloud. He then introduced me to an epidemiologist at a mid-western Children’s Hospital who focused on the relationship between air pollution and asthma. My noise sensor devices were used in conjunction with his air pollution sensor devices that capture ultra-fine particulate matter, since truck diesel engines are a source of both ultra-fine particulate matter and higher noise level

Next came my development of a lightweight wearable device measuring fine particulate matter. This device was worn by kids going to and from school with the goal of reducing their exposure to air pollution by either rerouting the kids away from trucks on their way to and from school, or rerouting truck traffic away from kids at certain times of the day.

He conducted other studies regarding the risks of air pollution in the home, in the community and the impact on the children’s health and cognitive functions at various ages of development, which resulted in development of my devices capturing information from a myriad of different sensors.

His upcoming work requires capturing air pollution information from various locations and making that information available real-time, to better understand where, when and the source air pollutions risk concentrations in the communities; not all that dissimilar to providing warnings to a dangerous algae bloom in the water or a shark close to a beach. As a result, my current device prototypes include identifying the sources of the particulate matter using computer vision and/or sound frequency analysis; and transmitting data real-time using low power cellular capabilities. 

Another area of interest is Covid-19, as a recent study has now linked air pollution to Covid-19 death rates.

Dr. Feder: So let’s set the stage. What are we talking about when we talk about air pollution? 

Mara: We’re talking about harmful particulate matter, gas, and vapor in the air. That includes smog outside and the air quality inside a building.  Indoor air pollution comes from cigarette smoke, carbon monoxide, household products, pesticides, mold, and building materials such as asbestos. Which is important to think about with schools and other buildings where kids are spending a lot of time.

Dr. Feder: Exactly. Patients who live or attend schools near highways or in cities may be impacted by automobile pollutants. Geography comes in to play as well. Mountains can trap pollution over a city … think about Los Angeles, Salt Lake City, and Mexico City. Arid climates and drought worsen air quality. Forest fires are a major source of air pollution—soot and ash are smaller particles that disperse widely. 

Mara: Everyone is affected by air pollution … but compared to adults, children are more likely to get respiratory infections, often spend more time outdoors, and may be less concerned about hygiene. 

Dr. Feder: That’s because children have a less developed respiratory epithelium. Once the body is exposed to potential pollutants it mounts an inflammatory response. The inflammatory mediators (IL-1 β, IL-6, and TNF α) can be neurotoxic and affect several areas of the brain including the prefrontal cortex and the hippocampus. The January issue of The Carlat Psychiatry Report did a full issue on the relationship between inflammation and depression, and you might have heard the podcast interview with Dr. Andrew H. Miller of Emory University in the February 10 issue of this podcast. Suffice to say, inflammatory response is linked to mental health issues like depression. And what we’re looking at is how children and adolescents are impacted. 

Mara: A recent study from California showed that teens exposed to more fine particulate matter had higher self-reported levels of anxiety and depression 

Dr. Feder: And it wasn’t just self-reporting. These teens actually had higher levels of autonomic reactivity—a physiologic marker for anxiety. Central Nervous System damage may occur through various mechanisms: neuroinflammation, oxidative stress, glial activation, and white matter injury. For more on the nature of air pollution, I spoke with ….

Mara: That’s really important to know. So it’s difficult to determine exactly how the pollution is affecting mental health. 

Dr. Feder: But it is pretty clear that the pollution is affecting mental health. The list continues: A British longitudinal study demonstrated associations between air pollution exposure at age 12 and depression and conduct problems by age 18. Research suggests a link between increased exposure to air pollution and decreased global IQ and psychomotor development, plus increased utilization of special education services in males. 

Mara: There is also emerging evidence around climate change or eco-anxiety occurring in kids and adolescents. They’re actually experiencing anxiety about the future of the planet.

Dr. Feder: Let’s talk more about that connection with asthma as well. A 2019 study reported that air pollution is responsible for up to 33% of incident asthma cases. 

Mara: Asthma is associated with a host of mental health problems, including internalizing problems. Youth with asthma may become more vigilant of their health, confuse breathing difficulties with symptoms of anxiety or anxiety attacks, or be more stressed by increased demands for self-care. Some inhaler formulations may also have side effects mimicking symptoms of anxiety.

Dr. Feder: The connection between asthma and psychiatric disorders seems bidirectional. Having the asthma makes the psychiatric condition worse, and having the psychiatric condition makes the asthma worse. That makes sense because having the possibility of an asthma attack is going to contribute to your anxiety. A possible upside to this is that improving the psychiatric condition might improve asthma control. That connection isn’t explicitly made in the literature, though. 

Mara: This is something to think about with patients who have smokers in the family. Secondhand smoke exposure increases asthma prevalence and severity, and predicts a child’s tobacco use. So, Josh. What can we do as clinicians about this. 

Dr. Feder: Three main things:

• Assessment
• Management
• Education

Mara: What do you mean by assessment? Are we getting out the stethoscope and listening to breathing?

Dr. Feder: Maybe, but chances are the pediatrician has that in the medical record already. It’s worth communicating with the primary provider about that because they can refer to a pulmonologist if that’s necessary. For our part, we can inquire about wheezing or shortness of breath, especially when a patient describes paroxysmal anxiety symptoms or problems during aerobic exercise. 

It’s also important to think about other modifiable risk factors for asthma. Things like:

• adolescent smoking
• Vaping
• possible exposure to secondhand smoke by peers or family members as you mentioned Mara. 

Mara: How are we managing this if it’s identified?

Dr. Feder: The first thing we’re doing is talking about it. We can address the impact of the child’s mental health condition on their physical state (eg, depressed and/or and not complying with medical treatment), as well as the impact of the environment on the child’s condition (eg, increased fatigue during a temperature inversion with reduced air quality). Another thing we can do to manage this is consider how children perceive the threat of air pollution. They may feel powerless and overwhelmed in the face of large-scale environmental problems. Fears of pollution may compound trauma in those affected by forest fires, for example.

Mara: Another example of addressing what’s in the news that may be impacting a child’s stress levels.

Dr. Feder: Yes, address the news in a developmentally appropriate manner. Explore children’s worries about air pollution, especially those living in communities impacted by temperature inversions and forest fires. Help them develop healthy, pro-social attitudes and behaviors about their environment. And we also know that parental stress impacts a child’s functioning, and studies suggest that adults who perceive their air is unhealthy are more likely to report feeling ill, headaches, and respiratory symptoms, regardless of the actual air quality. Since parental anxiety exacerbates child anxiety and symptoms, address parents’ mental health care so they are more responsive to their children.  

Mara: It seems like education is an important part of managing this. Patients may be experiencing this contributing factor to their mental health without even knowing about it or understanding it.

Dr. Feder: Knowledge is power. —-Observing factors—- OWL – Observe Watch Listen.

Mara: The first thing is trying to get people close to the child to stop smoking, if that’s part of the problem. 

Dr. Feder: Absolutely. It’s hard to overstate the positive impact that could have on a child’s development. Beyond that, we’re talking about educating patients and families about what air quality means. The Environmental Protection Agency provides prevention, technology, measurement, and science information that can be helpful to families, such as an overview of the current air quality index data. There’s links to that in the episode description. 

Mara: The CDC provides links to air quality forecasts to help families and schools figure out which areas may have better air as well as protective measures to minimize ozone and wildfire smoke exposure. Josh are we considering asking families to relocate?

 Dr. Feder: That’s a big step, and I expect we would probably be advising families about where to move if they were relocating already. I suppose if the symptoms were really severe and we felt strongly that air pollution was an aggravating factor it’s something we could suggest. Or maybe compare their memory of symptoms at different places they lived previously. Aside from a full on relocation … For families living near high-traffic areas or construction sites, encourage them to play and commute in areas with less exposure to pollutants, if possible. 

Mara: If it’s doable, I suppose we could encourage families to take vacations in areas with better air quality. 

Dr. Feder: And for patients who are especially vulnerable to air pollution, we can consider wearable sensor technology. That can help with measuring and improving air quality. For indoor irritants and toxins such as allergens and smoke, some home furnace systems are said to scrub the air, and air purifiers may be helpful; electrostatic devices purport to pick up indoor particles, such as those blown in from regional fires. It is unknown how well these consumer products prevent respiration of particulate matter, so buyer beware. 

Mara: When we first started looking at this it seemed like a very big problem that most individuals and families have little or no control over. However, after talking through it, I can see some practical steps that could make a difference in some treatment plans. 

Dr. Feder: Here’s the bottom line. You won’t fix all the problems related to air pollution during a med check appointment, but we recommend routinely asking about indoor and outdoor sources of environmental pollutants and helping your patients and families minimize these exposures. 

Mara: Links to the studies we’ve mentioned are in the episode description below. And if you want to read the full article, it’s in the Spring issue of The Carlat Child Psychiatry Report.

Dr. Feder: All the articles in The Carlat Child Psychiatry Report are free from industry bias. I don’t receive any funding from the pharmaceutical industry, and neither do any of our authors. We get all our support from readers.

Mara: If you pick up a subscription today, you can access all of the newsletter’s archives, which is pretty handy if you have a clinical question and need some practical answers fast.

Dr. Feder: And you also get access to all the CME post-tests, if you’re working on getting your credits together. 

Mara: Thanks for listening to us, and stay safe!

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