Vet $02 No LONG-TERM EFFECTS OF EXPOSURE TO LEAO — NEEDLEMAN ET Al % THE LONG-TERM EFFECTS OF EXPOSURE TO LOW DOSES OF LEAD 1N CHILDHOOD An U-Year Followsup Report Henoexr L. Neepueman, M.D., Avan Sonen., MA anp Euizanern N. Abstract To determine whether the elfects of low-level lead exposure persist, we reexamined 132 of 270 young adults who had initialy been studied as primary echoo!- ‘children in 1975 through 1978. In the earlier study, neuro: ‘behavioral functioning was found to be inversely related to entin ead levels. As compared with those we resiucied, the other 138 subjects had had somewhat higher lead levels on earlir analysis, as well as significantly lower 1G scores and poorer teachers! ratings of assteom be- ‘When the 192 subjects were reexamined in 1988, im- pairment in neurobehavioral function was stil found to be ‘lated to the lead content of teeth shed at the ages of ix and seven. The young people with dentin lead levels 20 ppm had a markedly higher risk of dropping out of high school (adjusted odds ratio, 7.4; 95 percent con- ITHIN the past three years, the Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry have conéluded in policy statements that lead at low doses is a serious threat to the central nervous systems of infants and children.'” These policy statements have been based om a growing convergence of resalts from both epice- riologic and experimental studies of lead toxicity in the United States, Burope, and Australia.** Whether the effects on the central nervous system of exposure (olow doses of lead that have been observed in infants and children persist has received limited attention. Only three follow-up studies have been published to date, and the longest follow-up has been five years." No data have yet been reported on whether early dis- tusbances influence fanetional abilities in later life In 1979 we reported that first- and second-grade children without symptoms of plumbism, but with clevated dentin lead levels, hac deficits in psychomet- ric intelligence scores, speech and language process: ing, attention, and classroom performance.’ When they were studied in the fifth grade, the children with high dentin lead levels had lower IQ scores, needed ‘more special academic services, and had a significant= ly bigher rate of fare in school than other children.? We have now evaluated the neuropsychological and academic performance in young adulthood of 132 of rom te Sch of Meine, Ut of Patugh, surg HL: ‘oor Ushers, Soaen (8); andthe Newepiertoy Unt, Chics’ Nospl sod Hara’ Mati Sal, Soran DD. ALL ENA). Adds rep eucts fo De Neves a he Unies ef Pisbg Scoal ef ‘etc: Wesera Pyne las eat Cle, 311 OF Se, Pau, Pests ‘Supper ya gat ($5 04095) mth Non osteo Enon ath cnet. Bre Baling work a suponed by 4 Reseach Cater De ‘slope var (5 00138) dine one 0 Bs ty Pend in pt a esol ming of Se Sct or Pete Resch AnancanPediare Sect, Watpion, D.C May 4,585 tne nna etn ee Davin Benuiworn, Pi.D., Ataw Luviron, M.D., ALLRED, MS, fidence interval, 1.4 to 40.7) and of having a reading ois- abilty (odds ratio, §.8; 95 percent confidence intonval, 1.7 to 19.7) as compared with those with dentin lead levels “<10 pom. Higher lead lovels in chiidhood were also sig- nificantly associated with Iower class. standing in high sschool, increased absentaoism, lower vocabulary and ‘grammatical-easoning scores, poorer hand-eye coord Nation, longer reaction times, and slower finger tapping, NNo significant assoclations were found with the results of 40 other tests of neurobehavioral functioning, Lead levels were inversely related to self-reports of minor delinquent activity, ‘We conclude that exposure to lead in childhood is asso- ciated with deficits in central nervous system functioning that persist into young adulthood. (N Eng! J Med 1980; 922:85°8.) the original sample of 270 subjects, and we report the relation of their recent performance to their exposure to lead, as measured II years ealir. Mernons Sample “he initia sample was chosen fo the polation of 1529 ch doen eli in the Bt ae secon grates in the Chen ad ‘Somerae, Masachutts, hoo systensbetwecs 199) an 198 ‘OF this popotnn, 10 pereen provided a lett one ofthe se rary tenth for ead anal, From this sample of 2555 cre, Si percent of whom were wt, we Sentfed 270 fom East Spetling homes whese lida dentin lead levels were rhe > Pom or 6 ppm. There children (mean age, 13 eas) ndervent "Mestre neurobebavgal examinaon: More eet were sue: ‘erly coleced abd analyed, and the aes wnt eth were ATbcorlan with eespect wo lead evel acorn toa prio ere ‘werecxlued rm the dts analysis Alo exci fram he a4. {ie ere cldcen who had not been dacharged from the hop Slherbireh at the ume Ge as Weir mother who had 3 netewardhy iced or wha ete epic to have had pmb! Ins later realy condacted in egpore to sggetions fom the Environment Protection gency. the on fea level at treated aga continous sare, A oean dentin lend level ‘Ginputed fr cach sabjettom all the ceth ocd, Th exc onary fctors previously wed were found not tobe ele to Sutcome ores The abject silly ented were three ot ‘eluded fom thi flap snmp “The 270 nubjetscesed frown 1975 wo 1978 consi he base poplin fc ths report From old rexeacch records leone ‘Trewors, town teary aad drvevsicese ral we Lee 197 subjetu, OF thee, 192 agreed to paripate and thee training #5 doling The subjects were pd $35 cach sd eeccved travel expenses, Ten sbjet ested in 188 ad bee exci om the analy reported In 1079 Beaute thee parents sated a the time of toxine tha the cin had elevated bec fed eves ‘Nl undergone chelation frleadpotoning. This goup is ducused feparately i ths Teport. The meat age of the 132 wujeete the 108 reexamination IBF yace the mean length tine ‘etgen the wo examination was 1 yar All ut our sje Jn'he crea llowup stay were whe No cael mania {iane of ead exporune wore corded nthe aver Irie fav the 28 subj who were a ested wits celta agents,w ‘THE NEW ENGLAND JOURNAL OF MEDICINE, The esearch protca and inleemed- content procedures were ap- proved by the natittional review boards the Childrens ovptal {1 Fitsborgs and the Children's Hospital, Boston. Informed eon ‘sen was given by all dhe subjects or thle parent, Classification of Lead Exposure All he dentin en levels measured from 1875 through [977 were sed to compute an arithmetic mean lend concentrason foreach subject The lead Borden wes treated in two ways! aba interval ‘arable in inca regressions and a8 categorical vatiable — te, high (20 ppm), seu (10 19.9 pp, and low <0 ppm} in the logis regressions described below. Lead level in venous lod were mearured athe tine of the recamination to estimate ‘ertent exposure. Tis practice was discontinued ater the rst 48 subjets were teste because none had a lead level exceeding 0.9¢ ‘nal per iter (7 gg per deciliter), well below the Centers for Die ‘nae Gonirls defmigon of wndue lead exporure of 1-25 rol per Tier (25g per desir), ‘Benavioral Evaluation “The subject were evaluated lndvidually by = single examines, whe remained blinded to their leac-exposure statve nnd all the Sate nad been coded and entered into » computer data base Issessmerts were cared out in a fixed order; the duration of the testing was about (vo hours. ‘Neurobehavoral Evauation Systom “The subjects completed an avtomated assessment battery ig which she used personal computer, joystick, and response hey. ‘We sectd the foloming items fom the battery for evslation Conte prance ek ‘Symbol igt ubitiuien an adaptation ofthe Wechsler item or computer administaion ani crdination. Using a joystick c0 move the cutso, the subject taced over a large sine wave generated on the monitor fereen; deviations fom the ine (font mean aquare ere) Were recorded. Sine ssuareact tine. Subjects pressed the response key when aa appeared on the screen the terval before the smn Tis wae varied randomly. Finger oping. Tae sabject pressed a response button as many times ns posible dering s 10-seeond period; both hands were tented. Fate meway. The subjec: was presented with 2 computer: generated pattern formed by a 10-by-10 array of dark and bright ‘ements, Afters bret exporur, the subject was presented with ftce pate, only one of which was identical to Ue orginal pattern Toe numberof correct responses and the leagthof time fo the core choice were recorded Paturs compris. The subject was presented with thee com putergeneraed patteres onthe LO-byi0 array. Two were ident fal and one dilfred aight rom thr other two, The subject was foaled to select the nonmatching patter. Soria tigi ling, The sobject was presented with a tring of 1W digi then asked ¢ eater the aving into the computer Alter sm ero the ame smolts presto, and the Second al bees Vacabder. For exch of 25 word, the subject chose the word most neany synonymous free alist of four choices ‘Granmalicl earning. The nibject we prevented with pie of leer A and By whose relative postion varie. Then the sreen Cleared, and the lstere were repned by = sentence that desribed the order of the Iter. The seateace might be active or pat tive alimative or negative, rue or false (examples ae "A fol lows B" and °B i not followed by A"), The subject had to chooks the correct enlencet, and the number of errors was reoorded. Jan it, 190) Swithing atten. The subject was require co choose which key to press in reponse fo three dierent insructtons, Tn the “ide” tal, uh subject had press dhe key an the same side as the nimlut Lathe “dieation” tril, dhe correct choice wat the direction in which an arrow pointed, efore each tat in dhe chr Set thesubjet was told whethar ochooae the side te sow was ‘on or the diveetion in which i potated. ‘Mood sale, Ths test was derived from the Pete of Moa State” Five scores were computed [or tension, anger, depres lon, tigi, and oafision, ‘The lowing eis were also used v evaluate neurobehaviorat funtion Caliornia Vorbal Leaming Test ‘The California Verbal Learning Tet" wae used tosses nat: ple strategies and processes invalved in verbal lereing snd mer fry. Scores for Immediate ued delayed recall wete also obvaind ‘Boston Naming Test Jn the Boston Naming Tea” the subject was presented with 0 pletares in order of increasing licully and asked name the bjcts shown. Rey-Ostereth Complex Figure Test ‘The Rey-Ostertith Complex Figure Tet! wat uted t evaluate vinual-motor and visual-spaal sila, The subject was asked 10 ‘copy an abetract geometric igure and then to draw it rom memoey both immediately and afer 30 mints, Acuraey’ and erganaation sees were ealttatd Wordtldenttcation Test Ferm B fom the Woodcock Reading Mastery Test was used to cvaluateteading sil. Grade-eqlvaleney sores were ealeulated fiom raw score. Kending disaity war defined as indicated by cores to grade levels below the scare expected on the bas o the ghee grade completed ‘So-Feponts of Delinquency ‘The subjects completed 2 structured queaionnaive fom the Ni sional Youth Survey that included scale for mint ata be havior and fr vekene crimes Roaview of Schoo! Records Highschool records were obtained fr al bat to ofthe subjects (ested, Class siee and rank, the highest grade completed, and che thumber of daye abyent and taedy in dh fst fll semester sere reorded. Students who were sin the 11th grade atthe time of {eating were not included in analyses ofthe highest grade compet ‘d. Clan rank war conmpited a2 1 ~ (elas ranh/las sa} Statistical Analysis “Tocyahute wheter the particpats in hit followup raluton were representative of the righ coor, sje who wee teed Sed tcedin 1908 ere empuetin em are rpred I'm acing den lend eves, covarter nor ene ad ‘peat, aches eatngt ear bebo, and Tsar. ‘tion, we cael eut separate rgrnsons of de ead [ove Zui iG score meme hewest 1076 a 1978 jes ‘Breland or tested 1988, We'hen perme reaenion on Sot oups ken ogtey, entering bot cry parti pation inthe cent falneup (eso te) a0 endl "Po eratoate te rlton between eal exposure fda ech of the commas dhbated cont vn, abject were lst aecoring to dented level quit, ad can cre, ‘djl fr vaneen, wee compte. Orsay essesqarsVa 22 Na 2 car egret, wit the teas o log-mean dent ead evel as ie inin elect, wa used to exon he signfcane af the Teton Gutetmes tat wer sigheany areca wih led eepeure i these bivariate anlyet vere Meter evahated by mulipe regres Sion anys Ten covariates warencladed in che mpl. They mere the mothers age atthe tne ol he aajets itty the motes uci! level, the mother 1, fry sam secloeconome {us (etwo-ftr Holingihead inde) eh, age at tne of tet ing. is oder, alahol ose ad whether the subj and the mth rie the hosp together afer the subec"s birth. The lend ‘ear (ibe mean ofthe lg the rea) tha produced the bes fied model (igh 12 reported. Five of hee eovarises were tnnplyed nce fst study ofthese bjs an shown oe a fal Five others (en, age a teting, prolonged hooptalization as hot, bird order and caveat aclu) were added to che tneel on te bss of prior knowledge thelr eects on psyco We function Logicregresion sly wa gn to de the SStition lea evel and to ostomes ested exegoreal ‘eee graduate Gom hgh schol and reading ds). tats fin we conti fr the covrtaes hed above, Two inden {ot varnies were ned to represen he the expat rus ‘Gaertn un 5 perce conBdene inven aed fo cava ines, were computed fr the High lead evel poup, wi the hw Ieedive group wed 3 de vlerence group. Resurs ‘Sélection Bias ‘The 182 subjects who were retested in|1988 (Table 1) were not representative ofthe group of 270 subjects tested in 1979. The subjects we retested tended to have slightly lower dentin lead levels, more highly educated families of higher socioeconomic status, and mothers with higher IQs and bewer obstetrical histories, a higher propostion of the retested subjects were girs In addition, they had had fewer head injuries and had significantly higher 1Q scores and better teachers? ratings 28 reported in 1979. The slope of the regres- sion of childhood 1Q on dentin lead level was steep- erin the group not ested in the fllownnp study, al- though the dilference from the slope in the group we retested was not statistically sg cant (F = 1.82, 1 196d P = 0.18) Academic and Neurobehavioral ‘Outcome Table 2 shows the covariate-ad- LONG-TERM EFFECTS OF EXPOSURE TO LEAD — NEEDLEMAN ET AL. es Table 1. Comparison of Susjects Tested and Not Testes in 1968," bevel eau) Mie 157 ze Hogs 33 a Pith aasi@ 018 Ne. of te bias Basie 0cs ater estos 114226 000 Maier eset n> 20222 leat ooms Monsees iets sase15 oon Moir’ ge stirs 25259 asaesa 07 ah Gr Fale age at abe waite me19 08 ‘ieaa estan ok) se9ez0 ao0s17 07 Binh we) snes 37rexeo 4 eo) Fame 52 ns Mie tar 33 006 ed ino (6) 3 47 098 Teaches’ aings (1979 um sore) 9.3828 42536 0006 atta 190979) lorsel¢ onsets apn covariates increased the odds ratio to 7.4 (95 percent confidence interval, 14 to 40.8). Higher dentin lead levels were also associated with lower class rank, increased absentecism, lower scores on vocabulary and grammatical-reasoning tests, significantly slower finger-tapping speed, longer reaction times, poorer hand-eye coordination, and lower reaeling scores. In subjects with dentin lead levels >20 ppm, the unad- jjusted odds ratio for having a reading disability, de- Fined by x score two grades below that expected for the highest grade completed, was $.9 (95 percent confi- ‘Table 2, Outcomes in Young Adutthoad According to Dantin Leet! Concentration in Childhood. eee iar as re rea wh aid not have elinical plum: tas . on bism, according to their dentin lead Reading score (words rvad corecits) 13.8 4an7 192 135.2 Shestheeesltsof modeling here. Mowtesisteertyseiocy 7113 mo lation between atly exposure to Satsang rents ta ko ve lead and outeome by multiple re- Mite fom sho of a * fresion, Barer expaure (@ lad St eis em ee 7 Ssignifcanty anos whale gemma pair ms mminatedacadericnucese. Among “tars Children with dentin fead levels Mey onda re >20 ppm, as compared with thore Mytrreo) as sas Ge ee pane eee eee pp, the nacJoxted odds ratio fo apa 0 9 sma gos failure to gracivate from high school was 4.6 (95 percent confidence in- yr terval, 1.2 10 17.4). Adjustment for {estan dna gay wll nT soar mn tinh bes eles6 ‘THE NEW ENGLAND JOURNAL OF MBDICINE Ja 1, 190 Table 3. Regression of Outcomes in Young Aduithood on Dent Laad Levels in Childhood." igs gate eed om -00r7 caw eating te equivalent ou one Cec eaning oon os Atsnc fom shalt oon 1 Gana! eons 0st one Veetiany 0108 pox Fes wping ast os iod-eyeceraon ona oor Reston tnt Prefered han ams na 608 Nonpetene hed aS bos Meer aii ehevirt nos | =n 08 007 = a0) 001 moor aoa) es 423 1 oa non Dime ang oxo -om om eon oes 013 nas or owe oo 0a oa oe oan 29 6 008 bose oe 103 Ss Oe 0.00 03m 07 asm “Ts wan wr meen a a Hh wha we sah nen et eB nm dn a "Tego eae ee rl a nd a ce dence interval, 1.5 to 10,5). Adjustment for covariates increased the odds ratio to 5.8 (95 percent confidence interval, 1.7 t0 19.7). For mest outcomes, neither the size of the lead regression coefficients nor their stand= ard errors were substantially changed by adjustment Tr covariates. OF the 10 children with clinical plumbism (who cither underwent chelation or were reported to have had clevated blood lead levels), 3 of 7 (43 percent) dropped out before graduating from high school (3 others are still in school), and 5 of 10 (50 percent) have reading disabilities. When the children with phumbism were grouped with the.other subjects ac- 8 oF | 120 1% Not Grating tom High Sehect ae 61 st [zer| over Denn Lea Level pe Figure 1, The Proporion of Subjects Who Did Not Graduate trom ign Schoo, Classtted According 0 Their Pasi Exposire ‘0 Lad Asymplomatic subjects are classed according to lead eve! {quarties. Sever of the 10 subjects who wore eater reported to hhave cinicalplumbism are shown in a soparate column. No ‘choo records were found forte subjects. One subject was not tested but roportod that she had graduated from high school (Thore ae therefore 121 subjactsrepresertedin ts figure) Ten subjects (toe wih reported plumblam and aeven asymplematic subjects) aro til attonding high schoo! and are therefore not ‘shown fora. The numbers in each column inleate the aumbor who didnot graduate and th total uraber in tho category cording to quartiles for dentin lead levels, a dose response relation was evident for both outcomes (Fig. Vand 2), Early exposure to lead was not significant associ- ated with performance on the symbol-digit ot serial- digit tests, the continuous-performanee test, pattern memory or pattern comparison, switching attention, the California Verbal Learning Test, the Rey-Oster. rcith figures, the Boston Naming Test, or maod scores, The lead level was inversely related to the summed score on the self-report of delinquency questionnaire, which consisted primarily of reports of minor antiso- cial behavior. When subjects were divided iato two groups act cording to their dentin lead levels (<10 ppm vs. #10 ppm), high dentin lead levels predicted future failure {0 graduate from high school with a seusitivity (SE) of 0.7120.12 and a specificity of 0.61:40.05 (Table 4). Discussion In this extended follow-up study, in which the mean length of follow-up was 11.1 years, we found that the associations reported earlier between lead and chil dren’s academic progress and cognitive functioning persisted into young adulthood. The persistent toxi ty of lead was seen to result in significant and serious impairment of academic success, specifically a seven- fold increase in failure to graduate from high school, lower lass standing, greater ahsentecism, impairment of reading skills sufficiently extensive to be labeled reading disability (indicated by scores two grades be- low the expected scores), and deficits in vocabulary, fine motor skill, reaction time, and hand-eye coord nation, ‘A number of issues require consideration when one is interpreting the data reported here, The first is the influence of setection bias on the associations we ob- served, The subjects retested in 1988 had more favor- able characteristics than those who could not be locat- ed or who declined to participate. The subjects who ‘were not retested tended to have had higher lead lev=Vol st No.2 Lone. ‘stn Reaing aby 8 ‘aan ea Lou fen) Figure 2, The Propartion of Subjects With Reading Disabiltos, Cassifod According to Their Pact Exposure to Lead. Asymptomatic subjects are cassiied accowting to leacvevel {uatie, and 10 chien with fistory of cinica plumbism are shown separately. Reading sabi Is defined es inleatod by 2 reatlng level wo or more graces below the expected leva. The ‘numbers n each column indicate the number wit a reading ds+ ably and the tla) number inthe category. dls, lower socioeconomic status, and lower! IQ scores and teachers’ ratings of classroom behavior. ‘The in- verte relation between dentin lead levels and 1Q re- ported in 1979 was stronger for the subjects who were not retested in 1988 than for those we retested, al- though the difference did not reach statistical sig- nificance, This finding is in agreement with the obser- vation, made by us and others, chat children from families in lower socioeconomic groups are more vul= erable tthe effects of lead than children from more favored economic backgrounds. We infer that the estimates made on the basis of the data on the 132 Subjects we restudied are likely to be conservative. Indeed, had all the original subjects been located and retested, the magnitude of th effect af lead exposure right have been even greater. Ts the nature of the relation beween lead and later outcome causal, or does it result from confouning by other variables? The association between lead and fouteome reported here mects six eriteria for valid causal inference: proper temporal sequence, strength of association, presence of a biologie gradient, non- spaciousness, consistency, and biologic plausibility." Tn this stady, the exposure to lead preceded the school failure and the reading disabilities: measured. ‘The strength of the association, as measured by ad. jsted odds ratios of 7-4 and 5.8, was substantial. A dose-response relation has been demonstrated be- tsecen exposure and numerous outcome variables (Ta- ble 2, Fig, Land 2). "Nonspuriousness” indicates that the association observed is not due to confounding. In {his analysis, ve controlled for both the covariates that were identified in 1979 as potential confounders and others we suspected were important. The magnitude of the effect of lead was reduced only slightly, if at all, by this procedure. The zero-order correlation between socioeconomic status and dentin lead levels ERM BESECIS OP EXPOSURE TI) LEAD — NEEDLEMAN ET Al o in this sample was not great (r = 0.04). Many covar- iates that were important contributors to performance in the early grades (eg., the mother’s 1Q and the tother’s educational level) had less effect on the subject's performance in young adulthood. ‘The re- sults, moreover, are consistent with those of several other studies by workers who have reported lead- associated deficits in reading*®® and early classroom behavior." The leadsrelated deficits in 1Q, speech and language processing, and attention reported in 1979 provide plausible mechanisms by which lead could impair performance in class and produce even- tual failure, Similar effects on learning have been demonstrated in the experimental studies by Gilbert and Rice of subhuman primates.” In these investiga- tions, rhesus monkeys, administered lead only in the first 100 days of life, had impairments in learning as adolescents. In adolescence, the mean blood lead level of these monkeys was 0.73 mol per liter (15 paz per deciliter). ‘The value accepted as the threshold for lead-enges dered neurotoxicity in children has declined steadily over the past decade as more sophisticated population studies, with larger samples, better designs, and better analyses, have been conducted." When this study was begun in 1975, the toxic level of lead in the blood was defined by the Centers for Disease Contral as 2.0 yumol per liter (40 jg per deciliter). In 1973, the mean blood lead level ia a subsample of 23 ch céren chosen from among those with the highest dentin ead levels in an carlicr study was 1.7 jumol per liter (G4 ng pee deciliter).* None of our subjects were symp- tomatic. That these subjects were exposed to high cioses of lead after the original study was completed is ‘unlikely. Lead exposure, the incidence of pica, and jouth behavior diminish after the fith year of life, The tow blood lead levels found in these sub- jects in young adulthood (all <0.034 mol per liter) provide convincing evidence that their later exposure to lead was not excessive, ‘The consensus on what level of lead is toxic has changed in recent years. After reviewing the studies published up to 1987, the Agency for ‘Toxic Sub- stances and Disease Registry defined the threshold for neurobehavioral toxicity as 0.5 «© 0.7 pinol per liter Table 4. Ser ity and Speciaty of to Dentin Lead Level in Chidhood asa Predictor of Faure to ‘Graduate trom High School * Ye » “ senna Speiony ‘Situ partir cee8 ‘THE NEW ENGLAND JOURNAL OF MEDICINE (10 0 15 g per deciliter}. The agency estimated that 3.t04 million American children have blood lead lev- els in excess of 0.7 jumol per liter. The mean blood level among our subjects with high tooth lead levels, ‘estimated in 1979 from a limited lead-sercening pro- gram, was 1.6 mol per liter (34 yg per deciliter) (range, 0.87 to 2.6 jmol per liter [18 co 54 wg per deciliter]). For subjects with low tooth lead levels, it was 1.2 mol per liter (24 wg per deciliter) (range, 0.58 to 1.7 mol per liter [12 to 36 ag per deciliter)). ‘Thus, the lead levels in the reference sample used in the calculation of the adds ratios for one high-lead~ level group were relatively high by contemporary standards, The data presented here indicate that exposure to lead, even in children who remain asymptomatic, may have an important and enduring effect on the success inlife of such children and that eatly indicators of lead burden and behavioral deficit are strong predictors of | poor school outcome. For the small group of 10 sub Jects who were diagnosed earlier as having plumbism, the outcome was especially dire; hall of these young people have reading disabilities, and almost half left high school before graduation. Given the federal est- mates that 16 percent of children in the United States have elevated blood lead levels (>0.7 mol per liter (15 jug per deciliter]), the implications of these find- ings for attempts to prevert school failure are intrigu ing, The practical importance of early detection and abatement of lead in the environment, before it enters the bodies of children, is borne out by these long-term findings in young adults. ‘We ae indebted to Drs, Richasd Frank, Constantine Gatsonl Alun Mirsky, and Rolf Loeber for ther earful esi and ertiques ofthe manutern¢ andl wo Me Pat Hadiian fr her carta wore Finding subjects snd reviewing records Reverrncrs 1. geo Tone Stnces a iene Regie. The ate neve (te peonngncnron a he Ui Stace sepa Cores. Ala Deptt cf Hea 2 Altay ene for ed Research Trg Pat, N.C: Brome Foston Agee, RG, 4 Newman HL, Gua C,Levioe A el. Dect in ocho and Sm inn wi Seva eee Nh Net ame, 4. Rohn Rhy Toman G Linen Hote R phn W. nes ‘tal ad on th liye men of ce rng, Lact 5: nee ON. Tinsel A, Bes I, nah T, Orns PA neo Procol! uy of hea wi cova denn lier see fief of lad in dierer sono pow. Liner SE Hacbinion 1, ade Hen mata in eerie Imation tere, Ne rts. Eur, Seda! CEP Const 1907 Jaa. 1), 1980 6, BellngeeD, Lavoe A, WneransC, Nestle above M Lon ‘tl nce pola oa ad spn a Sgt Sve cevetepeat. Eng) Med 195, 16:1057-43. thet SG, Ree DC Low-level tin le expan pres bir Iolo iui Saati revert i nn meer Tot Apt Pras (087, S48 90. 8 Cory DA, Wes B, Con, ely keh ony ed wth Fereanng etpome concern. Tout Apl Parte 71342 9. Beier, Neti HL, Bred Ry Mis M.A flowop sy of ‘he neater tne a entoon thi es wk lead ‘nn ad eves Bil Tac lam Res 1936 6207-23, 10, Eran C, Landa, Stall NS, Sete lvl of end and develop ‘nena dts malate flowap reeset Pee (98; 1, Seteeser SR, Has B, Ono DA, Mask P Hes RE Sepang te ‘ec of ea and scl ft 9 1. Enon Ra 585, aS, 12, Neelomia HL, Cele SK, Pah Led rd 1Q see 4a, 15, Bate EL, Low Re, Paler AT, haat, aauan DA competed ‘eobhivioal wt evalaia stem fr scapes en atonal {Bevel eons, Re oa 1M, Rome HE. iy AE, Season, Bamome SD, eck L.A amine us perme Bln cage Cana aye 1986 20363 & 1s, Metal DM, Lor My Oroplenan LF. EIFS aan — pole of od ‘ee, San Dig Edocaom td Teta Servic, 17) 16, Date. Krre JH, Kopin , Ob BA. "The Caer verte fap eran ein, San Atma Te Salt Cynon ie 17, Koplo E,GonilssH, Welt S. Honor ming ot, Padi LenB Fier 183, (fey A. Lotanenpotabglqu dn es xe Cenceppatie arn. Aue Ach Poel (961 25:30630. 19, Hl DS, Hatings AD, Agctoe SS. pln ingens apse ‘every ls, Cat Sage Pleo, 1085 28, HeligerD, Leon A, Waterss C,Neelomas Wi Rabmowse BL (crete exponnn socal didi dcop, Neto Tre tetpen 10090 53, 21, RIVA The niet sod eet: ora orcas? Poo RS 22, Forget DM, Foyuion 22, Hoooal L}, Kiet NO. & lout ty of ene vel lian, hoo eran and ay {ler Demine ad ont pave se. 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