The yard inside 11-year-old Cesar Gaspar’s Santa Ana apartment complex is cluttered with bicycles and scooters, but it’s the barren patches of dirt along the walkways that became Cesar’s dusty domain when he discovered marbles as a young boy.
From the age of 2, Cesar would spend hours knuckled down in the dirt. When his younger brother, Peter, was old enough, he became Cesar’s marble playing buddy, said their mother Kenia Gaspar.
What Kenia didn’t know at the time was that this playtime could be endangering her children. She said she constantly reminded her sons to wash their hands. But that would not protect them from inhaling the dust or ingesting dirt particles on their hands.
“Their fingernails were always filled with dirt, and I’d have to force them to wash their hands because they didn’t want to clean them,” said Kenia in Spanish.
Finally, she stopped buying the boys marbles, believing it was best to avoid the dirt altogether.
She was right. The soil in their yard contained lead.
This wasn’t the family’s first experience with lead exposure: Fifteen years ago, Kenia and Cesar Gaspar Sr.’s eldest daughter was hospitalized for lead poisoning while living in a different apartment on the same street in Santa Ana.
It was the first time Kenia learned of the dangers of lead, a toxic metal that was once a common additive in gasoline, household paints, and numerous other everyday items, and has been all but phased out from such uses over the past four decades.
Her then 2-year-old daughter Nadia’s lead-poisoned blood required a two-week stay in the hospital for chelation therapy. Typically children are hospitalized when blood lead levels reach acute stages — at or more than 45 micrograms per deciliter — and the child shows symptoms such as vomiting and abdominal pain . Nadia had those symptoms.
When a patient requires that level of medical intervention, county health officials are supposed to follow up with an environmental investigation. Kenia said nobody checked for possible sources of lead at her apartment complex. Her daughter’s experience left Kenia with more questions than answers as to how and why her daughter was poisoned.
“That seemed strange to me because given that my daughter was so sick you would think that they would investigate,” said Kenia. “But nobody came to look into the issue.”
“My daughter was so sick you would think that they would investigate, but nobody came to look into the issue.”
At the time, Kenia wondered if the peeling paint in her complex was to blame. She also suspected the soil because Nadia liked to play with and eat the dirt outside her apartment. But she wasn’t able to confirm her suspicions.
After the hospitalization, Kenia said her daughter appeared physically fine, but the end of Nadia’s hospital stay didn’t signal the end of the family’s lead-related ordeals. They were just beginning.
A few years later when she started school, Nadia struggled to learn to read and write. She couldn’t focus in class, wouldn’t participate in school activities, and earned low grades, said Kenia.
“Sometimes I would go to school with her, and I would go to her class with the goal of helping her focus, but I didn’t know that the lead could have impacted her academics — that it could still be affecting her,” said Kenia.
More and more evidence suggests Kenia’s instincts were right.
A majority of the nearly five-dozen residential lead soil tests conducted by ThinkProgress at or near the apartment complex where the Gaspars live tested positive for lead, but fell into the range below the level that California’s Office of Environmental Health Hazard Assessment considers harmful to children.
Kenia wasn’t aware that these lower lead levels in the soil are hazardous for young children, nor did she know that airborne exposure to lead-contaminated dirt can have long-term effects on the developing minds of young children and their behavior.
She said the issue never came up in school meetings, local health fairs, or even at her pediatrician’s office.
“The truth is I didn’t know anything about lead,” said Kenia. “I would just ask [at the doctor’s office:] ‘why do you do the blood test’ and they would say ‘to measure the blood,’ but I never asked more about it.”
“I didn’t know that the lead could have impacted her academics — that it could still be affecting her.”
Laboratory results show that when Cesar and Peter were tested at age 2 for lead, both boys had levels below 3 micrograms per deciliter (mcg/dL)—below the 5 mcg/dL threshold at which the U.S. Centers for Disease Control and Prevention (CDC) recommends public health intervention for children under the age of 6.
However, the federal agency has determined that no level of lead in children is safe. Lead exposure can have irreversible neurotoxic effects on the developing brains of children, and elevated blood lead levels can lead to increased aggression, lack of impulse control, hyperactivity, inability to focus, inattention, and delinquent behaviors.
For years, the Gaspars struggled with the behavior of both Cesar and Peter in school and at home. Cesar was particularly aggressive and defiant and had struggled in school since kindergarten, said Kenia.
It was only in March 2015, when Cesar was in fourth grade, and after battling school officials for years to provide him with a thorough special education assessment that he was officially diagnosed with attention deficit hyperactivity disorder (ADHD). Peter was given the same diagnosis.
Today, experts say that low level lead exposure, even blood lead concentrations below 5 mcg/dL, affect not only a child’s intellectual and academic abilities, but are also a risk factor for higher rates of neurobehavioral disorders such as hyperactivity and attention deficits.
“I never imagined that lead would be an issue for my children in this way,” said Kenia.
Finding new links between lead and cognitive disorders
In early 2016, Oregon Health & Science University’s Doernbecher Children’s Hospital announced a groundbreaking study that demonstrated a causal link between blood lead exposure and attention deficit hyperactivity disorder (ADHD), and also found that lead exposure in minuscule amounts increases symptoms in some people with ADHD.
OHSU Professor Joel Nigg, the study’s principal investigator, said that he and fellow researchers found these effects at levels below 3 micrograms per deciliter in the children who were part of the study, published in Psychological Science in late 2015. In all, 386 children (ages 6 to 17 years) from Michigan participated.
The study focused on a gene that controls the effects of lead in the body, and found a gene mutation that results in an increase in iron uptake. Because lead interacts with iron metabolically, this gene mutation is believed to alter the effects of lead and increases symptoms among those with ADHD, particularly hyperactivity-impulsivity, according to the study.
Nigg, a professor of psychiatry and behavioral neuroscience at OHSU, said he and his fellow researchers found this gene mutation’s effects in children with blood lead levels as low as 0.5 mcg/dL.
“One of the concerns…is that a lot of parents are being told ‘Oh, your kid doesn’t have any lead because they’re below 3 mcg/dL, but when you [measure] down to 0.3 everybody has some lead,” said Nigg. Among the children tested for the study, he says 99 percent had lead in their blood at least at those low levels.
While lead exposure does not guarantee an ADHD diagnosis, Nigg said that based on the study’s findings, lead does play a role and is one of the causes of ADHD at low levels of exposure.
“One of the concerns on our end here is that a lot of parents are being told ‘Oh, your kid doesn’t have any lead.’”
The federal government doesn’t urge public health intervention at levels below 5 mcg/dL for young children, and neither does the state of California. And many laboratories that test children’s blood lead levels don’t measure below 3 mcg/dL, making it impossible to track precise levels for children in this range.
But Nigg said that given lead’s effects at these lower levels, communities should re-examine detection limits for blood screenings conducted both in pediatrician’s offices and in laboratories that conduct screenings at the county or state level, said Nigg.
“A lot of kids, they’re called safe when their blood levels are screened, probably aren’t safe in reality,” said Nigg. “And [the ThinkProgress] soil tests would raise flags about that, I think, for anybody that tests these kids to see what their blood levels are.”
Yet even if children with low blood lead levels were properly identified, they wouldn’t qualify for intervention services in California.
“A lot of kids, they’re called safe when their blood levels are screened, probably aren’t safe in reality.”
“Since 2013, the Orange County Health Care Agency in California has sent parents and health care providers letters advising re-testing for children with blood lead levels between 5 and 9 mcg/dL, but no guidance or services are provided for children with levels under 5 mcg/dL, said David Nuñez, the agency’s family health medical director.
Further, in California, up until July 2016, only children with one blood lead test at 20 mcg/dl or higher, or two tests 15 mcg/dL or higher were considered lead poisoned by the state’s definition and would receive case management, such as a home visit, an environmental investigation, and case monitoring, typically from county health care agencies. Last July, those thresholds were lowered: one test 15 mcg/dL or higher, or two tests 10 mcg/dL or higher.
But even those thresholds are still too high to activate services for children whose blood lead levels are under 5 mcg/dL and can experience serious consequences such as loss of IQ points, behavioral issues, and educational delays.
“The bottom line is… there’s plenty of evidence from us and from others that all the way down to less than 1 mcg/dL there’s reason to worry about the effects of lead on children’s brain development, whether it’s IQ or ADHD,” said Nigg.
In the past, skeptics of lead exposure have blamed the children as being “bad kids,” said Nigg. And despite the mounting evidence, legislatures have feared investing in lead remediation citing their skepticism in the causal link as well as other contributors and factors that affect youth behavior and delinquency, he said.
“People know enough to say ‘Isn’t it pretty complicated? There are all these other factors.’ Well sure, but in fact, the science can address those things pretty well and we still see these causal effects,” said Nigg.
The impact of lead on a child’s brain
Almost a decade ago, University of Cincinnati Professor Kim Dietrich released the findings of a study that examined the long-term effects of lead exposure on a group of Cincinnati children. The study provided the first evidence that children exposed to lead in the mother’s uterus or during early childhood have an increased risk for criminal behavior later in life.
Lead is particularly dangerous for children because organs that are still developing are more vulnerable to environmental toxins, said Dietrich, director of epidemiology and biostatistics at the university’s College of Medicine.
The brain is especially sensitive to lead because lead affects calcium metabolism—essential for healthy brain development.
Dietrich’s study found that childhood lead exposure impacted areas of the brain — such as portions of the prefrontal cortex — that are responsible for mood regulation, decision-making, and the anticipation of consequences for one’s own actions. Lead also affects the hippocampus, which is important for learning, and the striatum, which is key for motivation, according to Nigg.
Hundreds of studies on animals have also shown that the effects of lead are long lasting. These studies show that lead can interfere with iron, zinc, and other metals that are necessary for neuro-transmission and in the process changes gene expression in these brain regions, said Nigg.
The effects of lead on behavior may endure even when the lead is no longer in the blood, he explained.
“So even though you get lead out of the blood in a few months it doesn’t guarantee that you’ll reverse the effect on the brain that the lead had when it was there,” said Nigg.
Researchers also have yet to uncover the length of lead exposure that results in the reduction of IQ points or causes ADHD, he said.
What is clear, based on his research, Nigg said, is that lead plays a role, in combination with other factors, by adding to the load on a child’s nervous system.
“If you’ve got a lot of stress in the family and on top of that you’ve got an unhealthy diet, and on top of that you’ve got a vulnerable genotype, suddenly you’ve got ADHD. So lead is part of the mix and probably other chemical pollutants are as well,” said Nigg.
The difference between lead and other chemical pollutants, Nigg pointed out, is that lead is the most studied, best-known, and most understood pollutant.
“I think of it as a good example of the larger problem of chemical exposures on kids’ health, and it’s sort of the most obvious and easy to see example, and the most upsetting example because we’ve known lead was bad for kids’ development for 60 years and we’re still arguing about whether to do more about it,” said Nigg.
So although environmental lead levels, such as leaded gasoline emissions, have been greatly reduced over the past 40 years, the number of children with ADHD continues to climb with each national count, said Nigg, in part because low levels of lead in the environment continue to have effects on children.
The latest figures from the CDC show that about 11 percent of American children (age 4 to 17) have been diagnosed with ADHD. Research has shown that having a blood lead concentration greater than 1.3 micrograms per deciliter is associated with a higher risk for ADHD in children, and approximately one in five cases of ADHD among U.S. children have been attributed to lead exposure, according to a 2016 American Academy of Pediatrics policy statement on childhood lead toxicity.
The research of epidemiologist Bruce Lanphear has also shown that children with low to moderate blood lead levels experience the most IQ point loss. Children lose 6 IQ points on average when blood lead levels are at 10 micrograms per deciliter or lower, compared to a loss of two IQ points when blood lead levels are between 10 to 20 mcg/dL, said Lanphear.
“We see the steepest decrement in learning ability, the steepest decrement in IQ at the lowest levels of exposure, which is really why the CDC said there’s no safe level of lead,” said Lanphear, a professor of health sciences at Simon Fraser University in Canada.
This loss concerns Loyola University Chicago School of Law Faculty Member Emily Benfer, who has spent half a dozen years working in collaboration with health providers, legal aid workers, and law students to help low-income families battle toxic living conditions in lead-contaminated Illinois neighborhoods.
In a 2015 report on health inequities, Benfer found that:
- Children with blood lead levels as low as 3 mcg/dL have lower end-of-grade test scores.
- 3-year-old children with blood lead levels of 4 mcg/dL are more likely to be classified as learning disabled in elementary school.
- Children with blood lead levels of 5 mcg/dL are 30 percent more likely to fail third grade reading and math tests, and to be non-proficient in math, science, and reading.
“We know that even at very low levels of exposure that lead poisoning leads to brain damage, it leads to reduced IQ, diminished intellectual academic abilities, academic failure, juvenile delinquency, developmental delays, learning disabilities. These are all impairments that the special education system is designed to help a child cope with,” said Benfer in an interview.
“We see… steepest decrement in IQ at the lowest levels of [lead] exposure, which is really why the CDC said there’s no safe level of lead.”
One study by Harvard University Professor David Bellinger found that lead toxicity accounted for an estimated total loss of nearly 23 million IQ points among a 6-year cohort of contemporary U.S. children.
Lead is among the prime examples of chemicals and pollutants that increase children’s risks for neurodevelopmental disorders, according to a group of scientists and environmental health advocates who issued a national call-to-action last summer. The group concluded that the current system for evaluating scientific evidence and making health-based decisions about environmental chemicals is “fundamentally broken.”
“We are witnessing an alarming increase in learning and behavioral problems in children,” noted the statement by Project TENDR (Targeting Environmental Neuro-Developmental Risks), citing ADHD, autism, and other developmental delays.
The group also pointed out that communities of color are disproportionately affected.
“We face a crisis from both legacy and ongoing exposures to toxic chemicals,” the group stated. “For lead, OP [Organophosphate pesticides] pesticides, PBDEs [chemical flame retardants] and air pollution, communities of color and socioeconomically stressed communities face disproportionately high exposures and health impacts.”
Labeled a troublemaker: One family’s journey to help their son
Cesar Gaspar had trouble focusing in class from the get-go in kindergarten. But instead of offering Cesar special education intervention, school officials labeled him a troublemaker, said his mother. She recalled how the school would call her constantly, asking her to pick up her son because he had gotten in trouble.
As he got older, Cesar’s behavior escalated and his grades suffered as a result. He got in trouble at school for hitting other students, or spitting in class, or pushing his teacher. He began telling his mom he didn’t want to go to school.
“He would act sick or he would cry. He’d say my head hurts, my stomach hurts, but he wasn’t sick. He didn’t want to go to school,” said Kenia.
“[C]ommunities of color and socioeconomically stressed communities face disproportionately high exposures and health impacts.”
For years, Kenia and her husband Cesar Gaspar Sr. asked for help from their son’s elementary school. But school officials said Cesar didn’t meet the criteria for special education.
This despite a seven-page special education evaluation that noted multiple issues with Cesar’s behavior, including hyperactivity/impulsivity, inattention, defiance/aggression, learning problems/executive functioning, and problems completing his assignments.
It was by happenstance that Kenia encountered mental health therapist Gabriela Hernandez in the lobby of her son’s school on a day that Cesar had gotten in trouble and was in the school office. Frustrated that the school was not doing enough, Kenia asked Hernandez to take her son on as a client.
Hernandez got to work, observing Cesar in class and at home, meeting with his teacher and other school officials. She praised his third-grade teacher whom Hernandez said tutored him during recess and after school so he wouldn’t fall behind academically.
But his behaviors in class were out of control, said Hernandez. He would get antsy, rock in his chair, play with something, or huddle under his desk while still participating in the class discussions.
Stress was also impacting Cesar’s behavior. At the time that Hernandez began working with the Gaspars, Cesar Sr., a painter, had completed a construction job and was working sporadically as a day laborer. The family was struggling to pay rent, didn’t always have enough money for food, and the children’s clothing was worn.
In addition to providing individual and family therapy, Hernandez connected the family with other resources, such as food and clothing banks. She also enrolled the family in a county wrap-around program, and enrolled Cesar and his younger brother in boxing classes at a local community center and a soccer league, where both began to thrive.
But the following year, when Cesar started fourth grade, the situation worsened. His relationship with his new teacher became tense, said Hernandez, noting that the teacher’s inability to control Cesar caused frustrations between the teacher and the boy.
As a result his teacher sent him to the school office so often, Cesar began to fall behind academically, said Hernandez.
The school, Monte Vista Elementary, had recorded two pages of behavioral complaints on Cesar going as far back as kindergarten.
A fight with another student was labeled as an assault. When he took a lighter to school, his record listed this as arson. When he scribbled the initials of the local gang in chalk on a school sidewalk, the school labeled him a gang member, said Hernandez.
Finally Kenia told Cesar: “I’m going to put you in a boot camp because I can’t tolerate this anymore… you’re not working with me.”
But Cesar cried and plead with Kenia: “No, mami, I’m going to behave.”
“But you don’t behave,” Kenia responded.
“It’s because I can’t behave,” Cesar told her.
A neurotoxin that ‘comes back to haunt you in many different ways’
The consequences of inaction on childhood lead exposure can be long-lasting, and because lead exposure is irreversible, it can create generations of families impacted by a legacy of lead contamination.
Once lead enters the blood stream, a majority of the toxin is deposited in a person’s bones where it accumulates and is then released, for example, during pregnancy when calcium from the mother’s bones is transferred to the fetus.
“[P]art of the tragedy of the whole thing is that 90 percent of the lead that you have in the body we have in the bones,” said soil lead expert Howard Mielke of Tulane University’s School of Medicine. “Exposure to lead takes place to the fetus at the period of time when they’re most sensitive to lead causing problems to the brain.”
Stress also triggers movement of calcium from the bones causing lead to re-enter the bloodstream, said Mielke. This in turn can cause confusion, and poor responses to stressful situations, such as temper flare-ups, he said.
And when an individual is sick or battling a disease that includes a fever, the body’s response is to draw on its calcium stores as well, releasing the lead in the process, said Mielke.
“So you have stress, sickness, aging, hormonal types of things, and normal pregnancy can all be affected by early lead exposure that in your full life span comes back to haunt you in many different ways, said Mielke.
Not all children who are lead exposed will end up in the same situation. A variety of factors can make children more resilient or more vulnerable, said Harvard University’s David Bellinger, an environmental epidemiologist and neuropsychologist who studies the effects of chemical exposures on children’s developing brains.
“Lead sets a child on a certain trajectory but what happens with that trajectory is affected by all these other contextual factors that may increase or decrease vulnerability to these kinds of bad outcomes,” said Bellinger.
When lead affects executive functioning this impacts an individual’s ability to delay gratification, think about the future and make decisions in light of a long-term goal, said Bellinger.
“So kids who have been impaired by lead in that way will probably not do as well in school, and they may drop out, because they’re not going to get much satisfaction from school and they’re going to look for it elsewhere,” said Bellinger.
Youth may make bad decisions due to executive dysfunction and impulse control problems, and in turn could end up running with the wrong crowd, join gangs and take actions that lead to short-term gratification, such as theft and other crimes, he said.
“But it isn’t a straight line because all of these other factors — parenting and how parents respond to the child’s difficulties, the degree to which there are neighborhood supports that may help the child deal with impulse control and help them find more productive outlets for their energies — all of those things are going to differ between children,” said Bellinger.
The issue facing parents is that neurodevelopmental delays in lead-burdened children may not become evident until the child starts school and learns to read in first grade, learns new reading material in third or fourth grade, and attempts to complete complex multistep tasks in middle school.
A diagnosis for Cesar
In 2015, with the assistance of the nonprofit Justice in Education and with Hernandez by their side, the Gaspars successfully petitioned to have Cesar re-assessed at school. The special education assessment concluded that Cesar has attention deficit hyperactivity disorder. (His younger brother would receive a similar diagnosis soon after).
This assessment allowed Cesar to qualify for special education services, including the help of a classroom aide who helps him with his behaviors and academic work, said Hernandez, who also connected the family with at-home tutoring for all four Gaspar children.
“My concern is how many children are placed on these gang registries or identified as at-risk when really it’s connected to a special need. And are they being advocated for?” said Hernandez. “And if you went back to look at all the kids who didn’t graduate or were placed on… these gang databases — did they have some special education impairment that was overlooked?”
Although lead poisoning is a disability under the Americans With Disabilities Act and Section 504 of the federal Rehabilitation Act, Loyola’s Emily Benfer said that typically, lead-burdened children do not receive special education services nor intervention to address the damaging effects of lead.
Those children whose behaviors aren’t treated are in turn more likely to head down a path that leads to juvenile delinquency, said Benfer. It’s why some Chicago providers are helping lead-burdened children to receive early intervention to address behaviors before they lead to juvenile delinquency, she said.
Some advocates in Illinois are also pushing for special education policy reforms that incorporate elevated lead levels as an automatic qualifier for special education intervention services, said Benfer, noting that currently a child can receive services only if they are diagnosed with the effects of lead poisoning, such as developmental delays.
“And if you went back to look at all the kids who didn’t graduate or were placed on… these gang databases — did they have some special education impairment that was overlooked?”
“If you had the chance to pull them from harm’s way you wouldn’t hesitate, and this is a prime example of an opportunity to do that,” said Benfer.
Tackling childhood lead exposure via collaboratives that involve school systems, law enforcement, and other public agencies could have a dramatic effect on childhood health outcomes as well as crime across the United States, said Benfer.
“We have to break down silos to really address this issue, and all of our different professions and community members must be involved in the solution, including crime prevention, police forces, government, and community members,” said Benfer, who also works as an advocate, lead poisoning prevention researcher, and co-principal of Health Justice Innovations, LLC, which addresses health equity and social justice issues by providing consulting, research and advocacy services to nonprofits, health centers, and communities.
And although remediating lead comes with a high price, the cost of inaction is much higher, she noted.
“We know where lead is,” said Benfer. “There’s no reason in this age where we’ve known this for over a century and we know the devastating harm and how it thwarts a child’s ability to thrive and steals them of their future — there’s absolutely no excuse for not addressing this today.”
Turning a corner: Cesar finds his footing
In retrospect, Kenia Gaspar said that had she known that ADHD was associated with lead exposure, she might have handled her eldest daughter’s lead exposure differently. She would have fought to ensure that her daughter received special education services to address her inability to focus and her struggles with reading, writing, and math in school.
“She was my first child and I didn’t know about [special education services],” said Kenia. “She might have needed the same services that my sons are receiving now, but I didn’t know then.”
Today, the Gaspars say their son Cesar’s behavior has improved greatly, and so have his grades. Playing soccer in a league has not only increased his self-esteem, it has given the family a chance to bond during the games.
“She might have needed the same services that my sons are receiving now, but I didn’t know then.”
“Good job,” Cesar Sr. called out to his son during a soccer game on a Saturday morning. Cesar maneuvered the ball across the field and kicked it toward his team’s goal. Cesar and his younger brother play for the same team, and the entire family attends his matches, including his older sisters. That day, the girls stood in the heat cheering “Go, Junior!”
Quick-footed and a fast runner, Cesar spent most of the game in action, stealing the ball from opponents, passing it to his teammates, and scoring two goals with their assistance.
After each goal, he looked toward his parents and beamed as his family whooped in celebration.
“That’s how you do it,” Cesar Sr. bellowed with pride.
“We know where lead is… there’s absolutely no excuse for not addressing this today.”
Now, instead of dreading school and begging his mom to let him stay home, Cesar rises early and leaves home before 7 a.m. to make sure he gets to class ahead of time, said Cesar Sr.
“Often he gets his things ready at night before school, and in the morning by the time I get up, he’s awake and he’s combing his hair,” said Cesar Sr.
But despite his progress, Cesar’s parents say his improvement is dependent on the intervention and support he’s receiving at school. Without it, he’d struggle, said Cesar Sr.
“I think that he’ll always need the services,” said Cesar Sr. “I don’t think that one year, two years or five years is sufficient. I think that he’ll need the services for his entire life.”
This project was made possible through the generous support of a community health reporting fellowship from the International Center for Journalists.