The Effects of Early Toxic Stress and Lead Poisoning on Learning and Development: Systemic Problems Require Systemic Solutions

Peter Simon is a pediatrician and public health expert who has worked at the Rhode Island Department of Health for nearly forty years, most recently as the medical director of the Division of Community, Family Health, and Equity, a position from which he retired in 2013.






For pediatricians, everything in our curriculum is targeted to developmental transitions: from the uterus to the external environment; from the hospital to the home; and from the home to social institutions, whether it be childcare or school and the community, and all the different systems – biological, social, environmental – that determine the outcomes for those.

Then we get into schools, and we’re not having that kind of discussion. We don’t get a good integrated understanding of how to improve outcomes for schools if we only focus on what goes on inside the school system. Sixty percent of Rhode Island’s urban school children have no formal exposure to an enriched early childhood education. Why isn’t there outrage over cuts in Head Start? Where’s the advocacy for Head Start coming from, besides the people who run Head Start?

We’ve got to do this together – and shame on us for not realizing that. We don’t talk the same language in public health and education. I have to acknowledge that when I go down to the Department of Education, they use terms that sound familiar to me, but they don’t use them the same way – what’s a screen? What’s an assessment? There’s a learning curve, and you have to be willing to support that.

Awareness of Childhood Lead Poisoning First Emerges

I was working at the Rhode Island Department of Health in 1977, when the Centers for Disease Control (CDC) issued the first request for proposals [RFP] on prevention of childhood blood poisoning. My boss asked me to present it to [then head of the department] Dr. Joseph Cannon. I told Dr. Cannon, “It appears from limited surveillance that there’s a real problem here. We have a lot of poor kids. We have a lot of old housing with lead in it. And a little bit of screening that’s going on just is yielding quite a significant load.” He said, “Where’s the lead coming from?” I said, “Most likely it’s coming from housing.” So he thought for about two seconds, and he said, “It sounds like it’s a real problem for kids in Rhode Island, for the state. It’s a real public health challenge. And I’m going to tell you to go ahead. But I’ve got to tell you right now, it’s a loser. You’re going to be barking up a housing tree that is loaded with politics and the worst kinds of human behavior. But go ahead.”

We got funded to increase screening and include screening as a routine part of a child’s medical care. We had to build up a lab capacity and an outreach. Those were some of the things that I learned the most from – the need to do cross-cultural, cross-linguistic health education outreach to families and screen their kids right on their doorsteps. We had a door-to-door summer campaign every summer, and I’d hire twenty-five college kids – representative of all the different ethnic, linguistic, minority communities in Rhode Island – train them about lead, teach them how to get a good finger stick sample, fill out the form correctly. We used to do 10,000 kids a summer. It was an outstanding model program of childhood lead poisoning control.

From Medical Problem to Public Health Issue

In 1993 or 1994, we were converting our screening test to an initial lead analysis on 35 to 40 thousand specimens a year instead of a preliminary screening using erythrocyte protoporphrin. The new screening strategy drastically reduced the number of lead-poisoned kids misclassified as negative, which tripled the number of positives that needed follow up. We didn’t have the capacity to actually intervene for all elevated lead tests, so we had to ration our inspectors and our inspections and our dollars, focusing on the highest end of the distribution. At that time, in South Elmwood, along Elmwood Avenue in South Providence, one out of two kids was poisoned – fifty percent of kids!

That’s the hardest communication challenge, because it’s not a medical problem. Now it’s a public health problem. You can talk about science till you’re blue in the face; the parents aren’t thinking about means or populations. They’re thinking about their kid and what it means for their family. Teachers are like parents – they’re working with twenty or twenty-five kids, but they’re working individually with each one of them.

If you ask early childhood educators, “How you can see the effects of lead in your preschool kids?” they’ll tell you: “They’re distractible. They’re easily agitated. Their working memory is poor. Their behavior and developmental profiles are immature in terms of their emotional volatility.” The descriptions you get of kids who are struggling to socially fit into a working early-childhood classroom overlap tremendously with the kinds of things that lead can do to the prefrontal cortex, the amygdala, hippocampus, all those parts of your brain that, when you talk about executive functions or you talk about emotional behaviors, all those functions are affected by lead.

And they’re affected by toxic stress. It can be difficult to distinguish from lead poisoning. You can’t do psycho-neurological assessments on preschoolers; they’re too young. There isn’t any real way of examining their brain, other than by observing their behavior. A good preschool teacher will tell you, and the kindergarten, first-, second- and third-grade teachers will, too.

From a public health standpoint, there’s a difference between measuring toxic stress and measuring lead, because we don’t have as many metrics yet; we don’t even have a definition. You have the Adverse Childhood Experiences (ACE) study, and the ACE scores. I think home visiting has some promise. Although what I learned from lead is that, in many of these neighborhoods and many of these households, lead gets you inside the door in a different way than home visiting. With home visiting on its own, the message could be interpreted as, “You’re broken and we’re here to fix you,” but with lead it’s that “There’s a threat to you in your home, put there many years ago, and if your landlord isn’t doing what they’re supposed to be doing, your baby, and you, could be at risk.” So the two together, if they’re well integrated, could perform very well.

Building on Our Progress: The Need for Adequate Resources and a Cross-Sector Approach

Since we started the lead program thirty-eight years ago, the percentages affected and new cases have been falling. Now, Rhode Island KIDS COUNT uses as an indicator kids entering kindergarten with a lead level over 5 – that indicator was one of the best things we ever did with our lead data.1 And KIDS COUNT has gotten a lot of good, positive feedback about that as a way of bringing attention from the preschool part of kids’ lives through the kindergarten doorway.

And from what I understand from talking to the people in charge of early learning in the Department of Education is that now the entire curriculum in K–3 is essentially an ongoing effort to identify and work with struggling students. So they don’t wait for the kids to fail. They’re constantly providing additional resources inside the classroom. And I think that’s fantastic.

However, when I know that resources are limited and I look at the lead data for each school in the state, which now we produce on an annual basis, I wonder when our General Assembly is going to weight the resources distribution with the challenges that are being brought into the classroom. The high lead level itself adds a risk, but it is also an indicator that a child comes from threatening and hazardous environments, and that brings toxic stress. Urban school districts need equitable support from our state funds.

We need to harmonize some of what we’re doing across public health and education. We can’t afford to keep operating in silos. Earlier care and education, healthy housing, food-system reform, and adult community building activities like community gardens and community agriculture have real promise to reduce stress and the toxic characteristics inside the home that are social and not environmental. An example is the West Elmwood Neighborhood Housing’s Sankofa initiative, which addresses these issues on an ecological level. I hope we can get people to understand the importance of collaboration rather than competition. We need more of an ecological approach, building on the assets we already have. 

Background on Child Lead Poisoning in Providence

Adapted with permission from Bucknell, S., S. Cullen, A. Dominguez, and D. Ochs, “Final Team Research Paper: Providence Children and Youth Cabinet,” Unpublished research report, Urban Education Policy graduate program, Brown University, 2013.

Childhood lead poisoning has been a problem endemic to New England for some time due to its industrial history. Providence had ten companies that produced potentially lead-based paints into the 1970s, as well as at least seven large companies that manufactured distilled gasoline and oil products that contained lead; and in contrast to other urban areas with relatively similar demographics, the city had no lead paint housing regulations until 1992 (Bailey, Sargent & Blake 1998). Providence did not successfully litigate against companies at fault for the lead poisoning crisis until 2006 (Fitzpatrick & Sprague 2006). The current prevalence of elevated blood lead levels (BLLs) in Providence is influenced by this history.

Catalyzed by litigation, a recent push to remedy past injustices and prevent future lead poisoning has had some success, but it has not eliminated the problem (Fitzpatrick & Sprague 2006). From 1997 until 2010, the incidence of elevated BLLs in children in Providence dropped dramatically, but Providence still had the highest rate of incidence of new cases of elevated BLLs in the state as of 2010 (Rhode Island Department of Health 2011). And Providence still faces an urgent lead poisoning problem, with 70 percent of housing stock in the city potentially lead hazardous (Rhode Island Department of Health 2016).

Certain neighborhoods within Providence experience a greater prevalence of lead poisoning than others. According to publicly available data maps from the Providence Plan (2012), a larger minority population and lower median family income seem to correspond to a higher percentage of children with elevated BLLs, indicating the inequitable distribution of lead poisoning in Providence.

The history of lead poisoning in Providence is further illuminated by considering the CDC’s evolving definitions and recommendations around lead poisoning (2012). Prior to 2012, the CDC set the blood lead “level of concern” in children with a BLL above 10 micrograms of lead per deciliter of blood. Based on research indicating the harmful effects of a lead level below 10, in 2012, the CDC re-evaluated the toxicity threshold for lead and their use of the phrase “level of concern.” The CDC now recommends that the parents of any child with a BLL above 5 be informed, and public health initiatives set into action. It is important to note that though the CDC calls the public to action at lead levels above 5, medical treatment is not recommended below 45. However, the CDC admits that there is no safe level of lead in the blood (2012).

Bailey, A. J., J. D. Sargent, and M. K. Blake. 1998. “A Tale of Two Counties: Childhood Lead Poisoning, Industrialization, and Abatement in New England,” Economic Geography 74:96–111.

Centers for Disease Control and Prevention. 2012. “CDC Response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention,” Centers for Disease Control and Prevention. 

Fitzpatrick, F., and A. Sprague. 2006. “Getting the Lead Out: How Public Nuisance Law Protects Rhode Island’s Children,” Roger Williams University Law Review 11, no. 3:603–649.

Providence Plan. 2012. “Rhode Island Community Profiles: Overview.” 

Rhode Island Department of Health. 2011. Core Cities Data: A Supplement to Childhood Lead Poisoning in Rhode Island: The numbers, 2011 edition. Providence, RI: Childhood Lead Poisoning Prevention Program, Rhode Island Department of Health. 

Rhode Island Department of Health. 2016. “Lead Poisoning Information for Landlords.”