July 23, 2007

Chemical Kids — Environmental Toxins and Child Development
By Dan Orzech
For The Record
Vol. 19 No. 15 P. 38

Developmental disability organizations have joined forces with environmental groups to persuade government and industry to examine the effects of toxic chemicals on child development.

We are adrift in a sea of chemicals. In the last 50 years or so, more than 85,000 industrial chemicals have been registered in the United States, and many have found their way into our environment—and our bodies. Children, with their smaller and still-developing bodies, may be the ones most vulnerable to chemical effects.

For decades, environmental groups have struggled to convince government agencies and various industries to consider the effects of these environmental toxins on children. Now, they are getting help from a new—and perhaps unexpected—direction: groups such as the Autism Society of America, the Learning Disabilities Association of America, and the American Association on Intellectual and Developmental Disabilities (formerly the American Association on Mental Retardation). These organizations, and dozens of others, have teamed up in an effort called the Learning and Developmental Disabilities Initiative, aimed at protecting children from pollutants that may undermine brain development.

There’s a growing body of evidence making a connection between how well children perform in school and everyday life and toxins in their environment. Lead poisoning, for example, has been shown to lower IQ and shorten attention spans. Children with high levels of lead in their body have more trouble concentrating and following directions and tend to not do as well in school. They are also more prone to impulsivity and antisocial behavior, including violence.

Most mental health professionals are likely aware of what lead poisoning can do to children, says Mary Rogge, PhD, associate professor of social work at the University of Tennessee who conducts research on children and chemicals in the environment. But there are a host of other chemicals in the environment, and many healthcare professionals, Rogge says, are unaware of the impact these toxins may have on children’s developing neurological and other systems.

Environmental Toxins
Environmental toxins that can affect children are frighteningly commonplace. Besides lead, there are other heavy metals such as mercury, which is frequently found in fish, that are spewed into the air from coal-fired power plants, says Maureen Swanson, MPA, director of the Healthy Children Project at the Learning Disabilities Association of America.

Mercury exposure can impair children’s memory, attention, and language abilities and interfere with fine motor and visual spatial skills. A recent study of school districts in Texas showed significantly higher levels of autism in areas with elevated levels of mercury in the environment. “Researchers are finding harmful effects at lower and lower levels of exposure,” says Swanson. “They’re now telling us that they don’t know if there’s a level of mercury that’s safe.”

Chemicals in pesticides are also a major source of concern. One class of pesticides, called organophosphates, has been associated with various kinds of cancer and hormonal disruption. Approximately 40 different organophosphate-based pesticide products are currently on the market in the United States. One, called Chlorpyrifos and sold under the name Dursban, was used on school grounds and playing fields and to get rid of household pests. Although Dursban is no longer sold in the United States, says Rogge, that doesn’t mean it’s not present in the environment. “At the time of the ban,” she says, “stores put Dursban on sale, and people stocked up, so they may still be using it.”

Another class of chemicals, organochlorines, have mostly been phased out in the United States. One of these chemicals, Lindane, was available as recently as 2003 as a prescription medicine to eliminate head lice and was associated with symptoms such as dizziness, headaches, and convulsions. Another organochlorine, dioxin, found in pesticides such as dichlorodiphenyltrichloroethane, has been banned from sale in the United States for some years. But dioxin, says Rogge, still enters the environment as a by-product of combustion from industrial processes.

Other chemicals that have been banned from use may still be causing problems as well. Polychlorinated biphenyls (PCBs), some of which are a form of dioxin, have been banned in the United States for years but are still found in the environment. Researchers have found evidence that children in the womb exposed to low levels of PCBs grow up with poor reading comprehension, low IQs, and memory problems.

Then there’s a whole category of chemicals known or suspected as endocrine disruptors. These chemicals can interfere with the human hormonal system, particularly the thyroid gland, says Swanson. During pregnancy, the hormones released by the thyroid are vital for normal development of the fetus’ brain.

Unfortunately, some chemicals make good flame retardants and have been widely used in everything from upholstery and televisions to children’s clothing. Studies have found them in high levels in household dust, as well as in breast milk. Two categories of these flame retardants have been banned in Europe and are starting to be banned in different parts of the United States.

Other chemicals, called plasticizers, just now are coming ontoCoding for Learning Disabilities
For The Record
Vol. 19 No. 15 P. 43

Learning disabilities are defined as “inabilities to acquire, retain, or broadly use specific skills or information, resulting from deficiencies in attention, memory, or reasoning and affecting academic performance.”1 Children with learning disabilities have trouble coordinating vision with movement and may be delayed in learning to read and write. In addition, they may have difficulty with communicating and controlling impulses. Other common symptoms include a short attention span, being easily distracted, a short memory span, hyperactivity, and being withdrawn, shy, or aggressive.

The ICD-9-CM code assignment for learning disability not further specified is 315.2.

Dyslexia
Dyslexia is a language-based disability caused by a brain impairment when interpreting images into meaningful language. Children with dyslexia, who usually have normal eyesight and average or above intelligence, have difficulty interpreting spoken language and writing. The common symptoms of dyslexia include the inability to recognize words and letters on a printed page, a reading ability level below the expected level for the child’s age, difficulty processing and understanding what is heard, and trouble understanding written words.

Although dyslexia cannot be cured, it is treated with multisensory teaching methods. Developmental dyslexia is classified to code 315.02 and dyslexia secondary to organic lesion to code 784.61. Code 784.61 is also assigned for unspecified dyslexia.

Dyscalculia
Dyscalculia (code 315.1) is a mathematical disability in which a person has difficulty solving arithmetic problems and grasping mathematical concepts. Some common symptoms include difficulty with abstract concepts of time and direction; the mistaken recollection of names; inconsistent results in addition, subtraction, multiplication, and division; poor mental math ability; an inability to grasp and remember math concepts, rules, and formulas; and difficulty keeping score during games.

People with dyscalculia have normal or accelerated verbal, reading, and writing skills with good visual memory of printed words.

Dysgraphia
Dysgraphia (or agraphia, code 784.69) is a writing disability in which a person has difficulty forming letters or writing in a defined space. Symptoms include poor writing skills but strong verbal skills, random punctuation, generally illegible writing, mixtures of print and cursive, unfinished words or letters, and inconsistent spaces between words and letters.

Dyspraxia
Dyspraxia (or apraxia, code 784.69) is difficulty planning and completing fine motor tasks. Children with dyspraxia may have difficulty using utensils, brushing their teeth, and working with buttons and zippers. If dyspraxia syndrome is documented, assign code 315.4.

ADD/ADHD
Attention deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD) is characterized by a persistent pattern of poor or short attention span and inappropriate impulsiveness. To diagnose ADD/ADHD, patients must exhibit at least six of the following symptoms in either group for at least six months to a disruptive and inappropriate level for the developmental stage:

Group A:

1. Often fails to give close attention to details or makes careless mistakes

2. Often has difficulty sustaining attention

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish duties

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

7. Often loses things necessary for tasks or activities

8. Often easily distracted by extraneous stimuli

9. Often forgetful in daily activities

Group B:

1. Often fidgets with hands or feet or squirms in seat

2. Difficulty with remaining seated when required

3. Often runs about or climbs excessively in inappropriate situations

4. Often has difficulty playing or engaging in quiet leisure activities

5. Often “on the go”

6. Talks excessively

7. Blurts out answers before questions have been completed

8. Difficulty in waiting for turn in games or group situations

9. Often interrupts or intrudes on others

ADD/ADHD may be treated with a combination of behavior therapy and psychostimulant drugs. ADD is classified to code 314.00 and ADHD to code 314.01.

Coding and sequencing for learning disabilities are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.