En i onmen al Resea ch 239 (2023) 117279
A ailable online 29 Sep embe 2023
0013-9351/© 2023 The Au ho s. Published by Else ie Inc. This is an open access a icle unde he CC BY-NC license (h p://c ea i ecommons.o g/licenses/by-
nc/4.0/).
Adop ing a child pe spec i e o exposome esea ch on men al heal h and
cogni i e de elopmen - Concep ualisa ion and oppo uni ies.
Ke s in Pe sson Waye
a
,
*
, Jespe L¨
o e
a
, Pe e Le che
b
, Angel M. Dzhambo
b
,
c
,
aa
,
ab
,
Ma ia Kla e
d
, Di k Sch eckenbe g
e
, Ch is in Belke
e
, La isa Leis
d
, Go dana Ris o ska
,
Sonja Je am
g
, Ka ja M. Kanninen
h
, Jenny Selande
i
, A zu A a
i
, Thomas Lachmann
d
,
z
,
Cha lo e Cla k
j
, Dick Bo eldoo en
k
, Kim Whi e
l
, Jo di Jul ez
m
, Ma ia Fo as e
n
,
Jaakko Kap io
p
, Gab iele Bol e
q
, Achilleas Psyllidis
, John Gulli e
s
,
j
, Hend iek Boshuizen
o
,
Alessand o Bozzon
, Janina Fels
, Maa en Ho nikx
u
, Pe e an den Hazel
, Mi iam Webe
w
,
Ma co B ambilla
x
, Ella B aa -Eggen
y
, I ene Van Kamp
l
, Na alia Vincens
a
, Equal-li e Scien i ic
Team
1
a
School o Public Heal h and Communi y Medicine, Ins i u e o Medicine, Uni e si y o Go henbu g, Go henbu g, Sweden
b
Ins i u e o Highway Enginee ing and T anspo Planning, G az Uni e si y o Technology, G az, Aus ia
c
Depa men o Hygiene, Facul y o Public Heal h, Medical Uni e si y o Plo di , Plo di , Bulga ia
d
Cogni i e and De elopmen al Psychology, Uni e si y o Kaise slau e n-Landau, Kaise slau e n, Ge many
e
Cen e o Applied Psychology, En i onmen al and Social Resea ch (Zeus GmbH), Hagen, Ge many
Ins i u e o Public Heal h o he Republic o No h Macedonia, Skopje, Macedonia
g
Na ional Ins i u e o Public Heal h, Ljubljana, Slo enia
h
A.I. Vi anen Ins i u e o Molecula Sciences, Uni e si y o Eas e n Finland, Kuopio, Finland
i
Uni o Occupa ional Medicine, Ins i u e o En i onmen al Medicine, Ka olinska Ins i u e , S ockholm, Sweden
j
Popula ion Heal h Resea ch Ins i u e, S Geo ge’s, Uni e si y o London, London, Uni ed Kingdom
k
Depa men o In o ma ion Technology, Facul y o Enginee ing and A chi ec u e, Ghen Uni e si y, Ghen , Belgium
l
Na ional Ins i u e o Public Heal h and he En i onmen , Ne he lands
m
Ins i u D’In es igaci´
o Sani `
a ia Pe e Vi gili (IISPV), Clinical and Epidemiological Neu oscience G oup (Neu o`
Epia), Reus, Spain
n
ISGlobal, Ba celona, Spain
o
Depa men o S a is ics, Da ascience and Ma hema ical Modelling, Na ional Ins i u e o Public Heal h and he En i onmen , Bil ho en, he Ne he lands
p
Ins i u e o Molecula Medicine Finland and Depa men o Public Heal h, Uni e si y o Helsinki, Helsinki, Finland
q
Ins i u e o Public Heal h and Nu sing Resea ch, Uni e si y o B emen, B emen, Ge many
Depa men o Sus ainable Design Enginee ing, Del Uni e si y o Technology, Del , he Ne he lands
s
Cen e o En i onmen al Heal h and Sus ainabili y & School o Geog aphy, Geology and he En i onmen , Uni e si y o Leices e , Leices e , Uni ed Kingdom
Ins i u e o Hea ing Technology and Acous ics, RWTH Aachen Uni e si y, Aachen, Ge many
u
Depa men o he Buil En i onmen , Eindho en Uni e si y o Technology, Eindho en, he Ne he lands
In e na ional Ne wo k on Child en’s Heal h, En i onmen and Sa e y, Ellecom, he Ne he lands
w
Ci y o U ech , U ech , he Ne he lands
x
Da a Science Labo a o y, Poli ecnico di Milano, Milan, I aly
y
A ans Uni e si y o Applied Science, Tilbu g, he Ne he lands
z
Cen o de In es igaci´
on Neb ija en Cognici´
on (CINC), Uni e sidad Neb ija, Mad id, Spain
* Co esponding au ho . School o Public Heal h and Communi y Medicine, Ins i u e o Medicine, Go henbu g Uni e si y, Box 414, 40530, Go henbu g, Sweden.
E-mail add ess: [email p o ec ed] (K. Pe sson Waye).
Con en s lis s a ailable a ScienceDi ec
En i onmen al Resea ch
jou nal homepage: www.else ie .com/loca e/en es
h ps://doi.o g/10.1016/j.en es.2023.117279
Recei ed 9 July 2023; Recei ed in e ised o m 27 Sep embe 2023; Accep ed 29 Sep embe 2023
En i onmen al Resea ch 239 (2023) 117279
2
aa
Resea ch G oup “Heal h and Quali y o Li e in a G een and Sus ainable En i onmen ”, SRIPD, Medical Uni e si y o Plo di , Plo di , Bulga ia
ab
En i onmen al Heal h Di ision, Resea ch Ins i u e a Medical Uni e si y o Plo di , Medical Uni e si y o Plo di , Bulga ia
ARTICLE INFO
Keywo ds:
Concep ual amewo k
Child pe spec i e
Men al heal h
Cogni ion
Exposome
ABSTRACT
Men al diso de s among child en and adolescen s pose a signi ican global challenge. The exposome amewo k
co e ing he o ali y o in e nal, social and physical exposu es o e a li e ime p o ides oppo uni ies o be e
unde s and he causes o and p ocesses ela ed o men al heal h, and cogni i e unc ioning. The pape p esen s a
concep ual amewo k on exposome, men al heal h, and cogni i e de elopmen in child en and adolescen s, wi h
po en ial media ing pa hways, p o iding a possibili y o in e en ions along he li e cou se. The pape un-
de sco es he signi icance o adop ing a child pe spec i e o he exposome, acknowledging child en’s speci ic
ulne abili y, including di e en ial exposu es, suscep ibili y o e ec s and capaci y o espond; hei suscep i-
bili y du ing de elopmen and g ow h, highligh ing neu ode elopmen al p ocesses om concep ion o young
adul hood ha a e highly sensi i e o ex e nal exposu es. Fu he , c i ical pe iods when exposu es may ha e
signi ican e ec s on a child’s de elopmen and u u e heal h a e add essed. The pape s esses ha child en’s
beha iou , physiology, ac i i y pa e n and place o ac i i ies make hem di e en ly ulne able o en i on-
men al pollu an s, and calls o child-speci ic assessmen me hods, cu en ly lacking wi hin oday’s heal h
amewo ks. The impo ance o unde s anding he in e play be ween s uc u e and agency is emphasized, whe e
agency is guided by social s uc u es and p ac ices and ice- e sa. An in e sec ional app oach ha acknowledges
he in e play o social and physical exposu es as well as a global and u al pe spec i e on exposome is u he
poin ed ou . To ad ance he exposome ield, in e disciplina y e o s ha in ol e mul iple scien i ic disciplines
a e c ucial. By adop ing a child pe spec i e and inco po a ing an exposome app oach, we can gain a comp e-
hensi e unde s anding o how exposu es impac child en’s men al heal h and cogni i e de elopmen leading o
be e ou comes.
1. In oduc ion
Men al diso de s a e a majo challenge globally also in young people
(WHO, 2021). Many child en and adolescen s wi h hese diso de s
emain unde diagnosed and unde ea ed wi h high indi idual and so-
cie al cos s (Kieling e al., 2011; OECD/EU, 2016). No ewo hy is ha a
child’s men al heal h, well-being and cogni ion ha e in insic alues,
beyond an ins umen al alue o subsequen heal h ajec o ies in
adul hood (UN, 2012; UNICEF, 2022). Se e al s udies indica e a
bi-di ec ional ela ionship be ween well-being and cogni ion o men al
heal h. Child en wi h men al ill-heal h show poo e academic pe o -
mance and quali y o li e ha can comp omise social and men al unc-
ioning la e in li e (Luby e al., 2017; Copeland e al., 2021; L¨
o e e al.,
2016). In addi ion, childhood cogni i e de elopmen p edic s educa-
ional achie emen and hus an indi iduals’ u u e p o essional ca ee
la e in li e. Mul iple ac o s ela ing o he child’s immedia e and gen-
e al physical and social en i onmen as well as gene ic p edisposi ion
may u he a ec he isk o men al ill-heal h. Toge he , his highligh s
he ele ance o an exposome pe spec i e o be e unde s and he
causes o and p ocesses ela ed o men al heal h, well-being, and
cogni i e unc ioning and o be able o ace back la e ou comes o ea ly
de elopmen al s ages (Mul aney e al., 2021).
The exposome concep , ini ially desc ibed by Wild in 2005 and 2012,
e e s o he o ali y o exposu es an indi idual is subjec ed o om
concep ion and o e a comple e li e ime. In his wo k, Wild classi ies
exposome in o h ee domains: 1) he in e nal exposome (e.g., me a-
bolism, endogenous ho mones, gu mic o lo a, in lamma ion, oxida i e
s ess); 2) he speci ic ex e nal exposome (e.g. adia ion, in ec ious
agen s, chemical con aminan s and en i onmen al and occupa ional
exposu es, die , li es yle ac o s); and 3) he gene al ex e nal exposome
including he social, economic and psychological in luences on he in-
di idual (e.g., social capi al, educa ion, inancial s a us, psychological
and men al s ess, u ban– u al en i onmen , clima e). The exposome
concep was in oduced as a complemen o he genome ini ia i e,
highligh ing he p essing need o conside he impo ance o bo h in-
e nal and ex e nal exposu es o heal h (Wild, 2005, 2012).
An exposome app oach, hence, allows us o assess a dose pe spec i e,
in e ac ion o exposu es and sensi isa ion by exposu e and he cumula-
i e isks (Smi h e al., 2015), aking in o accoun ime aspec s such as
c i ical pe iods o he heal h impac s. Fu he mo e, an exposome
app oach p o ides a comp ehensi e amewo k o s udy he causes and
mechanisms d i ing social inequali ies in heal h (Deguen e al., 2022).
Gi en he insigh ha an exposome app oach p o ides excellen
oppo uni ies o conside how child en’s de elopmen and men al
heal h a e a ec ed by he complex in e play o ex e nal and in e nal
exposu es o e he li e cou se (Vineis e al., 2020, Vineis and Ba ouki,
2022), he e a e su p isingly ew exposome s udies wi hin men al heal h
1
Anneke Bloks a; Sand a Boekhold, Jolanda Boe , Rik Boge s, John Bol e,
Ge da Doo nbos, Ju iaan Hoeks a, Sammie Jansen, Sanne Meije ing, Wim
Swa , Jacqueline Van Engelen, Elise Van Kempen, Kim Van Wijk, Ha m Van
Wijnen, Ma kus Viljanen, Albe Wong (Na ional Ins i u e o Public Heal h and
he en i onmen , Ne he lands); Yun Chen, Pe e F ibe g, Michael Smi h, Agnes
Wibe g (School o Public Heal h and Communi y Medicine, Ins i u e o Medi-
cine, Uni e si y o Go henbu g; Go henbu g; Sweden); Aleksei A onin, Ma iia
I ano a, Aino-Kaisa Pii onen A o Ala alo, Izaque de Sousa Maciel (A.I. Vi a-
nen Ins i u e o Molecula Sciences, Uni e si y o Eas e n Finland, Kuopio);
Ka h yn Adams, Yingxin Chen, Anna Hansell, Cal in Jephco e (Cen e o
En i onmen al Heal h and Sus ainabili y & School o Geog aphy, Geology and
he En i onmen , Uni e si y o Leices e , Leices e , Uni ed Kingdom); Jenny
Ah ens, Lena Gudi-Minde mann, (Ins i u e o Public Heal h and Nu sing
Resea ch, Uni e si y o B emen, B emen, Ge many); Ge d Ko uem, Vasileios
Milias, Roos Teeuwen (
Depa men o Sus ainable Design Enginee ing, Del
Uni e si y o Technology, Del , he Ne he lands); S en B¨
ol e, And ei Pyko,
Nes o Sanchez Ma inez, Libo Sulc (Uni o Occupa ional Medicine, Ins i u e
o En i onmen al Medicine, Ka olinska Ins i u e , S ockholm, Sweden); Nú ia
Bo ella, Bo is Che al, Payam Dad and, B uno Raimbaul , Ioa Ri as, Ca men
Peu e s (ISGlobal, Ba celona, Spain); Ch is oph Giehl, Jan Spilski (Cogni i e
and De elopmen al Psychology, Uni e si y o Kaise slau e n-Landau, Kai-
se slau e n, Ge many); Luc Dekoninck, Nele De Poo e e, Timo hy Van Ren -
e ghem, Sa ah Ve huls (Depa men o In o ma ion echnology, Facul y o
Enginee ing and A chi ec u e, Ghen Uni e si y, Ghen , Belgium); Gabin
D oua d, Uh; Ma ja Heinonen-Guzeje , Uh; Zhiyang Wang, Uh; Maud Dohmen,
Michail E angelos Te zakis (Buil En i onmen , Technical Uni e si y Eind-
ho en, Eindho en, he Ne he lands); Sa ah Benz, Julia Kuhlmann (Cen e o
Applied Psychology, En i onmen al and Social Resea ch (Zeus GmbH), Hagen
Ge many); Mihail Kochubo ski, Igo Spi oski (Ins i u e o Public heal h o he
Republic o No h Macedonia, Skopje, No h Macedonia); Ka in Loh, Julia Sei z
(Hea ing Technology and Acous ics, RWTH Aachen Uni e si y, Aachen, Ge -
many); Ma co Balduini, Anna Sandionigi (Da a Science Labo a o y, Poli ecnico
di Milano, Milan, I aly); Tanja V ijko e (Ams e dam UMC.).
K. Pe sson Waye e al.
En i onmen al Resea ch 239 (2023) 117279
3
on child en and adolescence (Haddad e al., 2019).) Whe eas p ena al
and ea ly-li e exposu es ha e been ex ensi ely app oached, his is o en
in ela ion o soma ic heal h ou comes (e.g., as hma, bi h weigh )
(Bu bank e al., 2017; Nieuwenhuijsen e al., 2019).
The Equal-Li e p ojec , pa o he Eu opean Human Exposome
Ne wo k, has unde aken he impo an ask o using an exposome
app oach o explo e he e ec s o exposome on men al heal h and
cogni i e de elopmen in child en and adolescen s, om concep ion o
age 21 (Van Kamp e al., 2022). The p ojec add esses pa hogenic and
salu ogenic exposu es in ela ion o men al heal h and cogni i e de el-
opmen in a heal h-disease spec um, adop ing a child pe spec i e on
exposu es, in akes and up akes. The p ojec applies an o en neglec ed
bu equi ed holis ic pe spec i e o child en’s men al heal h and
cogni ion. Wi hin Equal-Li e, he exposome is classi ied as ex e nal and
in e nal, whe e he ex e nal is subdi ided in o physical exposome (e.g.,
he buil en i onmen and en i onmen al quali y indoo s and ou doo s)
and he social exposome (e.g. socie al con ex , socio-economic, social and
psychosocial ac o s a he indi idual and con ex ual le el) and in e nal
exposome (p ocesses occu ing in he body, such as measu ed by p o-
eomics, me abolomics, epigenomics, gene exp ession and neu o-
imaging). The social exposome pe spec i e on child en’s and
adolescen s’ men al heal h and cogni i e de elopmen is speci ically
co e ed by ano he concep ual pape o he Equal-Li e p ojec o his
special issue (Gudi-Minde mann e al., 2023), and ocuses on p omo ing
he social en i onmen domain in o he exposome pa adigm, by simul-
aneously s essing he equi y pe spec i e. Equal-Li e u he in eg a es
da a a di e en spa ial and empo al g anula i ies and combines
explo a o y machine lea ning and hypo heses-d i en modelling (hie -
a chical eg ession, s uc u al equa ion modelling g ow h modelling,
e c.). Impo an p ojec hypo heses include po en ial media o s ocusing
on p ominen mechanisms om exposome o men al heal h and
cogni ion.
Wi h he aim o ex ending and deepening knowledge on how men al
heal h and cogni i e de elopmen a e associa ed wi h he child’s
exposome, we unde ook e iews o exis ing scien i ic li e a u e,
including empi ical and heo e ical pape s. The p ocedu e was
hypo heses-d i en and ocused on he mechanis ic pa hways, in es i-
ga ing how impo an media o s such as sleep, psychophysiological
s ess, es o a ion and sel - egula ion/coping could a ec he linkage
be ween exposome, men al heal h and cogni i e de elopmen . The
li e a u e e iew led us o ecognise a lack o ope a ionalisa ion and, o
some deg ee, he concep ualisa ion o exposome and, pa icula ly in
ela ion o how an exposome app oach would emana e om a child
pe spec i e. We also obse ed s ong ba ie s be ween scien i ic ields
wi h ew o e laps o na u al sciences, social sciences and medical and
heal h sciences, e en in seemingly ele an a eas, such as child de el-
opmen and he linkages o exposu e o heal h ou comes. Fo example,
exposu es desc ibed om a child pe spec i e a e ypically classi ied
om a na u al/medical science pe spec i e ocusing on dis ibu ion,
ime and equency o exposu es, while he social aspec s o how age-
speci ic beha iou a ec s he exposu e we e neglec ed. Fu he mo e,
age- ela ed exposu es could be seen as closely connec ed o social con-
cep s o place, ac i i y and he agency o child en and pa en s, siblings
and pee s, as has also been sugges ed in he Social Exposome amewo k
(Gudi-Minde mann e al., 2023), while biological pe spec i es, such as
age, sex, pe cep ion, up ake, in ake and me abolism, would be handled
in o he pape s. Finally, we also see ac o s ela ed o ou comes being
poo ly a ended o, such as diagnoses and exposu es, whe e he in lu-
ence o age, gende and cul u e a e o en neglec ed.
In an endea ou o b idge he iden i ied gaps, his pape add esses
signi ican concep ualisa ion and ope a ionalisa ion aspec s ha will
assis in emb acing a child pe spec i e wi hin he exposome ield, wi h a
ocus on men al heal h and cogni i e de elopmen .
2. Men al heal h and cogni i e de elopmen
The e ms men al heal h, men al ill-heal h, well-being, men al
illness, men al diso de s, and quali y o li e a e some imes used in e -
changeably o as complemen a y concep s, and de ini ions end o a y
in he li e a u e. Wi hin Equal-Li e, men al heal h is de ined as he
p esence o psychological o psychia ic illness o psychological ill-
heal h (psychopa hology), whe eas well-being e e s o posi i e psy-
chological heal h. Men al heal h is usually assessed and de ined wi hin
diagnos ic sys ems, i.e., DSM-V and ICD-11, p o iding diagnoses o o
example dep ession, anxie y o a en ion de ici hype ac i i y diso de
(ADHD). Fo younge child en and adolescen s, men al heal h can also
be assessed using symp om measu es (e.g., S eng hs and Di icul ies
Ques ionnai e (SDQ), Goodman and Goodman, 2009 o Mul idimen-
sional Pee Nomina ion In en o y (MNPI), Pulkkinen e al., 1999)
assessing o ins ance in e nalising and ex e nalising symp oms.
Well-being is pa o he Wo ld Heal h O ganisa ion’s (WHO) salu-
ogenic de ini ion o men al heal h: “a s a e o well-being in which e e y
indi idual ealizes his o he own po en ial, can cope wi h he no mal
s esses o li e, can wo k p oduc i ely and ui ully, and is able o make
a con ibu ion o he o his communi y” (WHO, 2004). E iden ly, his
de ini ion goes beyond he me e p esence o absence o men al diseases.
I also comp ises posi i e dimensions o heal h, such as hedonic
well-being co e ing dimensions like happiness, pleasu e and li e sa is-
ac ion, and eudemonic well-being co e ing dimensions like pe sonal
g ow h, pu pose in li e, and ela ions wi h o he s (Ryan and Deci, 2001;
Ry e al., 2021).
Men al heal h and well-being a e no o be unde s ood as ex emes o
he same dimension, meaning ha i is possible o ha e a men al dis-
o de diagnosis and s ill expe ience well-being. The impac o a men al
diso de will depend on access o esou ces in he immedia e social
en i onmen , conside ing he special needs o a pe son. Thus, some
child en wi h mild o mode a e symp oms will cope well in suppo i e
se ings, bu less well in challenging ones. This means ha he likelihood
o diagnosis o mani es a ion o beha iou al symp oms is also con ex
dependen .
Cogni ion is de ined as “ he men al ac ion o p ocess o acqui ing
in o ma ion and unde s anding h ough hough , expe ience, and he
senses.” Cogni ion is hus no a uni a y dimension and consis s o a ious
in e ela ed bu sepa able cogni i e unc ions. Fo cogni i e de elop-
men , in Equal-Li e we ocus on execu i e unc ions; i.e., cogni i e
p ocesses ha enable oli ional con ol o goal-di ec ed beha iou (e.g.,
selec i e a en ion, cogni i e lexibili y, wo king memo y, easoning,
p oblem sol ing, and planning (Diamond, 2013)), language and li e acy
unc ions, including phonology, syn ax, seman ics, lis ening comp e-
hension, eading, and spelling, e bal p ecu so s o li e acy ( e bal
sho - e m memo y, phonological awa eness) and school/academic
achie emen (Diamond and Ling, 2020; Mo eau, 2022).
3. Cu en concep ualisa ions and ope a ionalisa ions o
exposome
Despi e he g owing in e es , use and ele ance o exposome pe -
spec i es in esea ch, he e a e challenges in concep ualisa ion and
ope a ionalisa ion, pa icula ly o popula ions and ou comes less well
s udied. Since 2005, hese challenges ha e esul ed in p agma ic
esea ch app oaches, and al eady Wild p oposed exposome ca ego ies (i.
e., in e nal and ex e nal) and he need o “slice” he concep o deal wi h
he complexi y inhe en in his ield o esea ch. This p ac ice o “pa ial
assessmen o he o ali y o en i onmen al exposu es” was also no ed by
Haddad e al. (2019) in hei scoping e iew o he exposome. The
p ocesses o cha ac e ising and ca ego ising he exposome a e
commonly guided by disciplina y bounda ies, ou comes in ocus,
esea ch in e es s and agendas, da a a ailabili y o he abili y o collec
da a. Al hough mos s udies ollow he de ini ion om Wild, he ca e-
go isa ion and ope a ionalisa ion o he concep a e e ol ing wi h he
K. Pe sson Waye e al.
En i onmen al Resea ch 239 (2023) 117279
4
inclusion o o he domains o exposu es e.g., wo king li e exposome
(P onk e al., 2022), he p egnancy exposome (Robinson and V ijheid,
2015) o he u ban exposome (Robinson e al., 2018) and o di e en
omics (e.g., adduc omics, Vineis e al., 2020). Au ho s also use di e en
app oaches o he en i onmen al-heal h linkages in exposome esea ch.
Some sugges depa ing om he cha ac e isa ion o he ex e nal
exposome while o he s depa om he measu emen o he in e nal
exposome wi h indica o s in biospecimens (Rappapo and Smi h,
2010). Ideally, an in eg a ion o hese app oaches seems o ha e he
g ea es po en ial o answe ing he esea ch ques ions in en i onmen al
heal h esea ch as p oposed by (Zhang e al., 2021).
A hand ul s udies ha e in es iga ed he impac o exposome on
men al heal h in he young popula ion (Wang e al., 2023; Ke shenbaum
e al., 2014; Shaw e al., 2018; Robinson e al., 2015). The Helix p ojec
a ge ed se e al heal h ou comes in child en, including men al heal h
and cogni i e de elopmen (Mai e e al., 2018, 2021; Jul ez e al.,
2021; Bin e e al., 2022). Using an exposome app oach in ela ion o
child en’s beha iou al p oblems, cogni ion and mo o / e bal de elop-
men , hey highligh ed he nega i e and posi i e e ec s o selec ed
p ena al and childhood exposu es on indica o s o hese ou comes.
Cogni i e unc ion among 6–11-yea -old child en was analysed in
ela ion o 87 p ena al exposu es and 122 childhood exposu es (ai
pollu ion, buil en i onmen , me eo ology, na u al spaces, a ic, noise,
chemicals and li es yles) in ExWAS (Jul ez e al., 2021). The esul s
showed bo h expec ed associa ions be ween cogni ion and nu i ion and
indoo ai pollu ion and unexpec ed associa ions, i.e., highe g een
exposu e du ing p egnancy and low cogni i e unc ion. This led o he
au ho s e lec ing o e uniden i ied con ounde s and e e sed causali y.
In ano he s udy, using he A on Longi udinal S udy o Pa en s and
Child en, S ee e al. (2015) iden i ied ini ially 621 ou o 3965 en i-
onmen al a iables associa ed wi h a measu e o communica ion di -
icul ies among child en aged 9. O hese only 19 i ems emained in he
inal model, wi h ma e nal educa ion, social ne wo k and “ eel good
sco e” being posi i e p edic o s.
O he s udies in es iga ing men al heal h and cogni i e de elopmen
ha e ei he ocussed on social exposu es o explici ly on po e y
(B adley and Co wyn, 2002; Luby e al., 2013) o on physical exposu es,
mos o en chemicals (Shah-Kulka ni e al., 2020; Zhang e al., 2019),
whe e an exposome app oach would ha e allowed in es iga ion o
in e ac ing mul iple, complex, and concu en exposu es (Bu ke and
Mille , 2021; Reuben e al., 2022).
Social exposu es a e commonly ea ed as con ounde s and adjus ed
o in he inal analysis. This is pa icula ly p oblema ic as heal h in-
equi ies a e a majo challenge o socie ies. Fo example, low socio-
economic s a us and po e y impac ea ly age de elopmen wi hin
c i ical skills, such as language de elopmen , highe incidence o
lea ning diso de s and poo school ou comes (B adley and Co wyn,
2002; Tambu lini e al., 2002; Luby e al., 2012, 2013; Ha and Risley,
1995). Child en wi hin amilies o low socio-economic posi ion end o
li e and a end schools in low socio-economic a eas, leading o mul iple
s esso s. Clus e ing o s esso s o cumula i e exposu es add o heal h
isks (Apple on, e al., 2016; E ans e al., 2013; E ans, 2003; E ans and
Kan owi z, 2002; Wallande e al., 2019). In addi ion, adolescen s wi h
a g ea e numbe o isk beha iou (d ug use, poo sleep, poo die , isky
sex) end o be mo e s essed han adolescen s wi h less isky beha iou s
(Kwan e al., 2016). Fu he mo e, women om low socio-economic
posi ion ha e poo e nu i ion and end o wo k wi hin occupa ions
wi h highe physical and psychological demands, which may nega i ely
in luence oe us g ow h, including neu ological de elopmen (Bo ge
e al., 2017; Cai e al., 2019; Selande e al., 2019). While cumula i e
exposu es a e seen o add o he heal h isks, c i icism ha e been aised
as o whe he he concep is use ul o in e en ion measu es, aising he
need o mo e e ined s a egies (McLaughlin and She idan, 2016). A
gene al conclusion poin s o he impo ance o including bo h physical
and social exposu es and pa icula ly wi h e e ence o child en’s
physical o men al heal h and cogni i e de elopmen .
Schulz and No h idge (2004) we e ea ly in examining he e-
la ionships be ween social inequali ies, he buil en i onmen and social
con ex . La e , Tul e e al. (2016) de eloped a amewo k o he child’s
o al en i onmen ha included: in e nal (in insic biological ac o s),
buil , na u al and social en i onmen o he op imisa ion o heal h and
well-being among child en. These amewo ks we e among he i s o
acknowledge he impo ance o he social en i onmen on mic o, meso
and mac o le els, o indi idual, home/ amily, school/dayca e, com-
muni y and ci y/s a e/na ional le el, including ac o s such as he
economy, demog aphics, sa e y, wel a e, pee ela ions and amily
suppo . In a sys ema ic scoping e iew o pape s (2003–2013), Ruiz
e al. (2016) assessed non-chemical and chemical s esso s associa ed
wi h child en’s cogni i e abili y. The au ho s poin o a gene al lack o
s udies adop ing an exposome pe spec i e o e en pe o ming analyses
o mul iple exposu es and he need o mo e knowledge on complex
in e ac ions be ween exposu es and ac i i ies and beha iou wi hin he
o al en i onmen o a child, also add essed by Gudi-Minde mann e al.
(2023).
4. Adop ing a child pe spec i e o an exposomic app oach
A child’s exposu e and ulne abili y o in e nal, social and physical
componen s a y o e de elopmen al phases, anging om p econcep-
ion, oe al pe iod, neona al pe iod, in an , oddle , ea ly childhood,
middle childhood and ea ly and la e adolescence. Child en a e o e
hese ime pe iods subjec ed o a wide di e si y o physical and social
exposu es in places and imes, exposu es o e which hey ha e li le
con ol. Also, a child’s ulne abili y a ies due o hei ex ensi e bio-
psycho-social de elopmen . Child en also ha e a compa a i ely highe
up ake o exposu es due o hei physiology (E zel, 2020) and less
de eloped de oxi ica ion me abolism (Huen e al., 2012).
To p opose and adop a child pe spec i e o he exposome we
a icula e in his sec ion he concep s o ulne abili y, including he
no ions o suscep ibili y and equi y. The child de elopmen , ex ensi e
g ow h and in pa icula , he b ain de elopmen is explici ly discussed
in ela ion o he concep s o ulne abili y and c i ical pe iods. Fo he
in eg a ion be ween a ious exposu es (e.g., physical and social expo-
su es) and be ween exposu es and he indi idual, we apply he
s uc u e-agency heo y and he concep s o social p ac ices, places,
ac o s and ac i i ies.
4.1. Vulne abili y
The concep o ulne abili y is undamen al in ela ion o bo h child
de elopmen and heal h equali y. S ill, he a icula ion o he concep o
ulne abili y ends o a y ac oss and wi hin disciplines (Gudi--
Minde mann e al., 2023; WHO, 2019). I also depends on whe he he
esea ch ocus is on he indi idual o he popula ion. An indi idual ocus
comp ises he inbo ne and cons an ly e ol ing biological suscep ibili y
in di e en phases o human de elopmen om he p e-na al pe iod o
adolescence (e.g., c i ical and sensi i e pe iods), whe eas a popula ion
pe spec i e comp ises he di e en ial ulne abili y be ween g oups
wi hin and be ween socie ies which is essen ial o unde s anding how
heal h inequi ies e ol e and pe sis . To be e unde s and and ac on
heal h inequi ies be ween g oups in socie ies, Dide ichsen e al. (2019)
sugges a h ee-dimensional de ini ion o ulne abili y. The i s
dimension cap u es how di e en ial exposu e is unequally p e alen
among di e en g oups in socie ies (e.g., exposu es o noise, chemicals
and es o a i e a eas). The second dimension cap u es di e en ial sus-
cep ibili y (i.e., inequali y in he heal h e ec o exposu e), due o e.g.,
in luence o como bidi y, allos a ic load, gene ic makeup and epige-
ne ics (E ans e al., 2021) Thus, suscep ibili y migh change o e ime
and inc eased suscep ibili y migh be he esul o p e ious exposu e
(Chae e al., 2021). The hi d dimension comp ises di e en ia ion in ca-
paci y o esponse, which e lec how powe and access o esou ces (e.
g., inancial, social and ma e ial) enable a oiding exposu es and coping
K. Pe sson Waye e al.
En i onmen al Resea ch 239 (2023) 117279
5
wi h po en ial ad e se heal h e ec s (Dide ichsen e al., 2019). Again, i
is impo an o no e ha hese h ee le els a e no s a ic. Ra he , unequal
exposu e, suscep ibili y and capaci y o ac a e closely ela ed o o mal
(e.g., laws, egula ions, educa ional sys ems) and in o mal s uc u es (e.
g., no ms and expec a ions). Consequen ly, his h ee-dimensional
app oach o ulne abili y allows us o desc ibe he con ibu ion o
each dimension as well as hei in e dependencies and in his way migh
help us o a oid he pi all o labelling and s igma ising speci ic g oups
o communi ies as “ ulne able popula ions”. Ins ead, i acknowledges
ha ulne abili y om a popula ion pe spec i e is a ma e o con ex
(Chae e al., 2021). While his app oach has been ques ioned o
con la ing exposu e, suscep ibili y and capaci y o esponse, i cap u es
he no ion ha he indi iduals’ beha iou s, ac i i ies and places also
ha e an e ec on he exposu es.
4.2. The de eloping b ain
The p egnan mo he ’s exposu e o chemicals and me als may a ec
p ena al de elopmen and long- e m cogni i e de elopmen o he
child (Shah-Kulka ni e al., 2020; Zhang e al., 2019). P e-p egnancy
exposu es and p e-na al s esso s may also be ela ed o se e al
ad e se ou comes bo h in he sho e m, and long e m ( an den Be gh
e al., 2020). Highe le els o sel - epo ed s ess and o highe le els o
p egnancy co isol ha e been ound o be associa ed wi h g ow h e-
s ic ions and poo in an neu ode elopmen (cogni i e de elopmen )
(Capa os-Gonzalez e al., 2021). Some s udies also indica e an associ-
a ion be ween p e-na al s ess (in mo he o child) and anxie y symp-
oms in he child a ages 8–11 yea s (McGuinn e al., 2022).
Wi hin- amily s udies o exposed and non-exposed child en bo n o he
same mo he can p o ide es s o he pu a i e causal hypo hesis un-
de lying such associa ions (Skoglund e al., 2014; Li e al., 2020).
Rega ding p ena al s ess, co isol ou pu du ing p egnancy is one s ess
ho mone iden i ied as associa ed wi h neu ode elopmen , bu we lack
knowledge o all he mechanisms (Capa os-Gonzalez e al., 2021). In
con as o epineph ine, co isol c osses he blood–b ain ba ie and has
been associa ed wi h changes in b ain s uc u es in ol ed in cogni ion
(Gunna and Que edo, 2007). The e ec may be mo e o less ha m ul
du ing di e en ime pe iods o b ain de elopmen . Fo example,
ele a ed co isol le els ea ly in ges a ion was linked o lowe a e o
de elopmen o e he i s yea and lowe men al sco es a one yea o
age. Ele a ed co isol le els la e in ges a ion showed accele a ed
cogni i e de elopmen and highe men al sco es a 12 mon hs o chil-
d en (ibid).
Resea ch sugges s ha ea ly li e s ess is linked o p onounced e ec s
on he de elopmen o p e on al–hippocampal–amygdala ci cui s
(McEwen and Mo ison, 2013). Apa om playing a la ge ole o he
pe iphe al s ess esponses, including he HPA axis, he p e on al
hippocampal-amygdala ci cui s a e associa ed o emo ions,
sel - egula ion, memo y, and lea ning (ibid) and ch onic ac i a ion o
hese ci cui s o men al and physical heal h issues (Nusslock and Mille ,
2016). Hippocampal olume may be educed among child en exposed o
ea ly li e s esso s (Hanson e al., 2015), and changes in hippocampal
olume a e hough o be linked o de ici s in child lea ning p ocesses.
(Pech el and Pizzagalli, 2011).
The co ical o ganisa ion and s uc u es o he human b ain a e
o med sequen ially om concep ion o young adul hood allowing hem
ime o be a ec ed by ex e nal and in e nal exposomes (Fig. 1). The
p ocess o neu onal g ow h and mig a ion o he de eloping pa s o he
co ex occu p edominan ly p ena ally (Hous on e al., 2014). Co ical
mo phology and densi y con inue o de elop du ing ea ly childhood and
adolescence and in o he la e wen ies. Du ing his ime, co ical
de elopmen p og esses om lowe -o de co ical s uc u es, wi h sen-
so y and mo o unc ions, o highe -o de , ans modal associa ion
co ical s uc u es wi h execu i e, socioemo ional and men al unc ions.
(Sydno e al., 2021). Du ing he de elopmen al phases, he social,
physical, and in e nal exposu es in e ac and help ine- une and shape
he a ious s uc u es in he b ain. When hese in e ac ions a e
hampe ed o i he e is in e ac ion wi h haza dous exposu es, he
de elopmen al p ocess is comp omised. While he child b ain is esilien
and malleable o salu ogenic in luence, such as suppo i e ca e and
s imula ing en i onmen pa ly balancing he nega i e exposu es (E ans
and Kan owi z, 2002), i s apid de elopmen and g ow h du ing
Fig. 1. B ain olume (g ey and whi e ma e ) de elopmen om he p ena al pe iod o young adul ohood in pa allel wi h examples o common ime pe iods o
clinical diagnosis o a selec ion o men al heal h diso de s. Adap ed om Be hlehem e al. (2022).
K. Pe sson Waye e al.
En i onmen al Resea ch 239 (2023) 117279
6
p ena al and e y ea ly age also makes i highly sensi i e o ex e nal
impac s.
Compa ed o adul s, hough, less is known abou how co ical
s uc u e de elops in ea ly childhood. Using he la ges da ase a ail-
able, 123,941 Magne Resonance Imaging (MRI) scans we e collec ed
and analysed o c ea e a cha o neu ode elopmen o e age, ocusing
on s uc u al MRI da a o main issues like he o al g ey ma e olume
(GMV) and o al whi e ma e olume (WMV) (Be hlehem e al., 2022).
I was ound ha co ical GMV inc eased s ongly om mid ges a ion
and du ing he i s yea s o li e, wi h a peak a 5.9 yea s. Whi e ma e
olume (WMV) also inc eased om mid ges a ion h ough childhood
wi h a peak a 28.7 yea s. (Fig. 1). A limi a ion o he da a is he lack o
di e si y globally wi h he majo i y o popula ions om No h Ame ica
and Eu ope. In e es ingly, a la ge p opo ion o indi idual a ia ion in
co ical GMV and su ace a ea (SA) a six yea s o age seemed al eady o
be p esen a one yea o age, while measu es o co ical WMV a he age
o 6 we e explained o a lesse deg ee by a ia ion a 1 yea s o age
(ibid).
Va ia ion in co ical mo phology is o in e es as i may be ela ed o
cogni i e unc ion, sleep pa e ns and neu ode elopmen al diso de s.
Fo example, au ism spec um diso de being associa ed wi h al e a ions
in co ical (GM) s uc u e, including inc eased co ical hickness (CT)
and (SA), while a en ion de ici -hype ac i i y diso de and conduc
diso de s a e sugges ed o be associa ed wi h non-no mal co ical GM
(Gilmo e e al., 2020). Indi idual a ia ion in sleep pa e n among
adolescence was also seen o be associa ed wi h b ain mo phology, wi h
o example g ey ma e olume in hippocampus being associa ed wi h
as e non-REM sleep spindle equencies (Sale in e al., 2013).
Fu he mo e, cogni i e abili y in in an s and child en has been associ-
a ed wi h indi idual di e ences in egional and co ical GM olumes, CT
and SA (Gi aul e al., 2020; Fenchel e al., 2022). The obse a ion ha
indi idual a ia ions occu a a e y ea ly age emphasises he impo -
ance o he igh iming o any suppo .
E en hough using such me hods as MRI gi es us a be e insigh in o
he de elopmen o b ain s uc u es and unc ional ne wo ks, we a e s ill
a he beginning o a mo e comp ehensi e unde s anding. A be e un-
de s anding o ac o s o impo ance o he de elopmen neu al sys ems
(Hous on e al., 2014) may aid in unde s anding impai ed neu o-
de elopmen and ela ed neu ode elopmen al diso de s, such as
A en ion De ici Hype ac i i y Diso de s (ADHD), Au ism Spec um
Diso de s and de elopmen al lea ning diso de s. This may be possible
h ough new me hods, such as unc ional MRI, which can p o ide in-
o ma ion on neu al ac i i y by measu ing changes in blood oxygena ion
le els. These measu emen s can be done when pe o ming, e.g., cogni-
i e asks and may p o ide mo e p ecise in o ma ion on he cohe ence o
neu al ac i i y wi h cogni i e de elopmen .
Cau ion is ad ised, howe e , in d awing conclusion om co ical
mo phology o neu al ac i i y alone as a consequence o haza dous in-
e ac ions, as animals s udies indica e ha he inhe en plas ici y o he
b ain allows o ca ching up a la e s ages (Hensch, 2005; We ke and
Hensch, 2015). I is also impo an o acknowledge ha he e a e la ge
indi idual a ia ions in b ain mo phology among heal hy child en, ha
he impac o co ical hickness (CT), o example, is compa a i ely
weak when compa ed o o he in luencing aspec s, such as ges a ional
age and ma e nal educa ion (Gi aul e al., 2020).
4.3. C i ical pe iods o suscep ibili y
The pe iod o childhood may be iewed as a succession o phases o
s ages wi h dis inguishable ana omical, physiological, and psychologi-
cal cha ac e is ics (Fi es one e al., 2007; Hubal e al., 2014). To acil-
i a e analyses and communica ion, Fi es one e al. (2007) de ined hese
pe iods as ‘‘a dis inguishable ime ame in an indi idual’s li e cha ac-
e ized by unique and ela i ely s able beha iou al and/o physiological
cha ac e is ics ha a e associa ed wi h de elopmen and g ow h’‘. The
s ages o pe iods a e commonly e e ed o as “c i ical pe iods” o
“windows” du ing which a child may be suscep ible o mo e likely o be
a ec ed by an exposu e. The s ages a e seen as sequences ha depend on
and in luence each o he , meaning ha ac o s a ec ing heal h de el-
opmen in ea ly li e (such as excessi e s ess, es ic ed physical ac i i y,
o poo ca e) may a ec a child’s u u e men al and physical well-being
(e.g., Smi h e al., 2015; E ans, 2003). In biology science, c i ical pe iods
o windows commonly adhe e o “pe iods o de elopmen when i is
obse ed in insic changes in biological sys ems owa ds inc easing
complexi y, g ea e adap i i y and mo e e icien unc ioning (Sco ,
1986), while in li e cou se epidemiology c i ical pe iod has been de ined
as “a limi ed ime window in which an exposu e can ha e ad e se o
p o ec i e e ec s on de elopmen and subsequen disease ou come.”
(Kuh e al., 2003). Fo example, high le els o p olonged p ena al
pa en al s ess du ing p egnancy and ea ly pos na al s ess o he
new-bo n can lead o impai ed neu ode elopmen du ing sensi i e pe-
iods o apid cell di ision h oughou oe al and pos na al li e. This can
ha e las ing nega i e e ec s on heal h and well-being h oughou he
li espan (Bleke e al., 2019; Rome o-Gonzalez e al., 2020; McGuinn
e al., 2022). In addi ion, s esso s a an ea ly age may also inc ease he
likelihood o pheno ypic exp ession o a gene ic p edisposi ion o a
neu ode elopmen al diso de (Lachmann e al., 2022).
Sensi i e pe iods a e some imes used in e changeably wi h c i ical
windows bu a e mo e o en used in psychological and beha iou al
li e a u e (e.g., Skogen and Ø e land, 2012; Nelson, 2000) and end o
desc ibe pe iods whe e an exposu e may ha e he mos p ominen e -
ec . New iews on c i ical windows highligh ha al hough adap i e
changes may p ima ily be modi ied ea ly in li e, he doo seems o be
open o li elong plas ici y (We ke and Hensch, 2015). Ques ions a e
he e o e “wha p ocesses open, media e, close o eopen he c i ical
windows” (ibid).
As a p oxy o c i ical pe iods o windows, age spans a e commonly
e e ed o, howe e he use o age spans di e s be ween cul u es and
scien i ic ields. In de elopmen al psychology age spans impo an o
de elopmen was sugges among o he s by E ikson and E ikson in he
ea ly i ies (Dunkel and Ha bke, 2017). These age spans ha e in lu-
enced clinical p ac ice, esea ch, and educa ion, including school
cu iculums.
Depa ing om a biological/na u al and paedia ic expe ise and
ocusing on a chemical exposu e assessmen s and isk assessmen s, he
US En i onmen al P o ec ion Agency (2005) and la e he Wo ld Heal h
O ganisa ion (WHO, 2006) unde ook he ask o de e mining age spans
based on ana omy and physiological de elopmen ha would a ec dose
and heal h impac . These a emp s we e subsequen ly e isi ed by Hubal
e al. (2014), who a emp ed o ha monise exposu e assessmen s o
compa e judgemen s ac oss place, cul u e, and ime. While hey s ess
ha he e is no single “co ec ” means o de ining he age spans, hey
poin ou ha using a s anda dised ca ego isa ion acili a es compa i-
sons be ween s udies and coun ies. They p opose o use he WHO
de ailed age span comp ising 12 age spans o a simpli ied e sion o
eigh age spans (see de ails in Table S1 in he supplemen a y ma e ial).
F om an exposome app oach, a ca ego isa ion o ulne able age
spans would ideally acknowledge psychosocial, cogni i e, and biolog-
ical de elopmen al age pe iods and hei ulne abili y o di e en ex-
posu es and pa hways o exposu es. The ini ia i e was al eady sugges ed
in he bio-psycho-social model de eloped by Ha ighu s (1956) and has
la e been explo ed bu mainly o adul ageing (e.g. F iedman and Ry ,
2012). We would p opose ha u u e e o s a emp o de ine an
in e disciplina y exposome-inspi ed age ope a ionalisa ion wi h a clea
child pe spec i e.
4.4. S uc u e and agency – a heo e ical app oach o unde s anding he
exposome in child en
In he de elopmen o a child pe spec i e wi hin he exposome ield,
we see he need o a oid me hodological indi idualism whe e indi iduals
a e pe cei ed as passi e ecei e s o exposu e o s udied sepa a ed om
K. Pe sson Waye e al.
En i onmen al Resea ch 239 (2023) 117279
7
con ex ual ac o s (F ohlich e al., 2001). To ha end, i has been sug-
ges ed o adop a sociological app oach: s uc u e and agency (Abel and
F ohlich, 2012; Ø e s een e al., 2017). In his app oach, agency cap-
u es an indi idual’s exp ession o will and capaci y o ac . Howe e ,
hese ac ions a e no execu ed andomly. Ins ead, indi idual easoning
and ac ions a e guided by he cons an in e ac ion wi h social s uc u es,
which may impose oppo uni ies and/o cons ain s o agency. The so-
cial s uc u es can be enac ed in he o m o laws, egula ions, and s a e
ins i u ions, bu also in he o m o no ms, expec a ions and pa e ned
beha iou o discou ses. In addi ion, and o g ea ele ance o ou dis-
cussion abou he exposome, hese s uc u es a e also mani es ed in he
o m o na u al o buil en i onmen s (Be na d e al., 2007). Impo -
an ly, s uc u es may enable and es ain agency disp opo ionally
be ween g oups in socie y, e.g., li ing wi hin neighbou hoods wi h
limi ed access o ec ea ional a eas may es ain physical ou doo
ac i i y.
Beha iou a ec s a child’s exposu e and may also a ec ou come.
Fo example, using social media la e a nigh migh nega i ely a ec
sleep and inc ease he isk o men al diso de s. On he o he hand, social
media use can be seen as an oppo uni y o social in e ac ions, he eby
p omo ing well-being. Ne e heless, many beha iou change models a e
c i iqued as naï e due o he p imacy o he indi idual and indi idual
choice, and his seems o be he case e en when “con ex ual ac o s” a e
conside ed (Blue e al., 2016). Social p ac ice heo y (Blue e al., 2016;
Malle , 2015) o e s a signi ican con ibu ion o he de elopmen o a
child pe spec i e o he exposome as i u he de elops he
s uc u e-agency nexus, ocusing on i s ma e ialisa ion as p ac ice. So-
cial p ac ice heo y hus combines “Ma e ials”, “Compe ences” and
“Meanings”, whe e ma e ials e e o objec s, consume goods and in-
as uc u es, compe ences e e o he unde s andings o si ua ions and
p ac ical know-how, and meanings add he social signi icance o he
p ac ice and pas expe iences o pa icipa ion (Blue e al., 2016). These
en i ies (ma e ials, compe ences and meanings) a e he basis o un-
de s anding a gi en p ac ice. I should be no ed ha a social p ac ice is
no a synonym o indi idual beha iou (Blue e al., 2016). Ra he ,
Malle de ines a p ac ice as:
being cons i u ed by meanings abou how and why o do hings
(cul u al con en ions, expec a ions and socially sha ed meanings),
ma e ials (objec s, ools and in as uc u es), and compe ences bo h
aci and explici (knowledge and embodied skills) (Malle , 2015).
Applying he social p ac ice heo y o social media usage among
child en and adolescen s migh include: 1) a sha ed unde s anding o
meaning o why o engage in social media, when o do so, how o en, bu
also wha o pos and wha in luence s o ollow; 2) ma e ials like mobile
de ices, so wa e applica ions, algo i hms, elec ici y; and 3) compe-
ences in how o download applica ions, na iga e he in e ne , cha ge
you de ice and sou ce c i icism. In addi ion, he p ac ice o social
media usage could be an in e ela ed pa in o he p ac ices, such as
going o sleep. Wi h his app oach, he p ac ice en i ies (meanings,
ma e ials, and compe encies) will a ec ou assessmen o he child
exposome in a comp ehensi e way ha assis s in he o mula ion o
adequa e in e en ions. Fo ins ance, i we aim o s udy child ele an
exposu es like a i icial ligh , we need o acknowledge he a ious pa s
ha de e mine media usage, i.e., how long, how o en, he use o sc een
il e ing, pa en al guidance, school demands and pee p essu e.
Apa om he de eloping agency o e y young child en (who ha e
less abili y o de ine and exp ess hei will and capaci y o ac ), we
highligh he ele ance o su ounding and signi ican ac o s (e.g.,
pa en s, p eschool s a and eache s), whose p ac ices migh a ec he
younge child and can be in es iga ed om a social p ac ice app oach, e.
g., b eas eeding, eading aloud and going o he pa k ( an Nijna en,
2010).
4.5. Places, ac o s and ac i i ies
Places a e unde s ood acco ding o human geog aphy and u ban
planning as loca ions ins illed wi h meaning (Tuan, 1977). Places e lec
in e ac ions among loca ions (locali y), he linkages o daily social ac-
i i y (locale), and indi idual/communi y sense o place (Cloke and
Johns on, 2005; Dohmen e al., 2021; Psyllidis e al., 2022). I is also
whe e social in e ac ions ake place (Gudi-Minde mann e al., 2023).
O e he li e cou se, di e en places (e.g., home, schools, na u e) ha e
di e en ial ele ance o people, some hing ha also a ies ac oss his-
o ical pe iods, ac oss coun ies, ac oss people and ac oss p ac ices
(C esswell, 2009). Concep ually, places a e aligned wi h ac o s and ac-
i i ies ha a e unde s ood acco ding o s uc u e-agency and social
p ac ice heo ies. Ac i i ies a e he eby unde s ood as speci ic ac ions o
ele ance o exposu e and o heal h equi y (Dohmen e al., 2021), e.g.,
exe cising and ea ing. A social p ac ice app oach will help explain how
o unde s and hese ac i i ies and hei link o exposu e, including social
s uc u es, indi idual choices and beha iou (Blue e al., 2016). In
Fig. 2, we p esen a concep o elabo a ing on how a child pe spec i e
can be app oached in exposome esea ch e alua ing men al heal h and
cogni i e de elopmen . The igu e should be seen as an e ol ing concep
ha may inspi e esea che s and o he s akeholde s in conside ing
ele an dimensions o he exposome concep ualisa ion, such as places,
exposu es, ac o s, ac i i ies, social p ac ice, and li e s ages. Conse-
quen ly, he ac ual con en migh di e depending on he esea ch ocus,
wi h he sugges ed places, exposu es, ac o s, and ac i i ies being al e ed.
As indica ed in Fig. 2, digi al engagemen is added as i has become a
place o g owing ele ance o he exposome om a child pe spec i e
(Odge s and Jensen, 2020). Howe e , i is impo an o acknowledge
ha he concep is no exhaus i e and ha i can enable o he ypes o
ex ensions when needed.
4.6. A child-pe spec i e on exposu es
Due o hei physiology (E zel, 2020) and less de eloped de oxi i-
ca ion me abolism (Huen e al., 2012), child en ha e a compa a i ely
highe up ake o exposu es as compa ed o adul s o mos en i on-
men al pollu an s. These physiological di e ences a e well known
wi hin he paedia ic medicine and pha macology, bu some imes
o e looked in en i onmen al s udies. Fo example, he ai in ake o an
in an is abou wice ha o an adul , and simila ly a child has a
conside able highe in ake o wa e and ood pe kilog am weigh (Moya
e al., 2004; Bea e , 1995). Child en up o he age o abou se en also
di e in ela ion o adul s ega ding di ac ion and e lec ion p ope ies
o he head, pinna, and o so ( he head- ela ed ans e unc ions; HRTF)
(Fels, 2008). As he a ia ions in HRTFs, a ec s noise exposu es a he
opening o he ea and wi h he addi ion o he esonance o he ea canal
u he a ec s he audi o y exposu e, his may ha e implica ions o
pe cep ion and discom o o highe equency sounds (Pe sson Waye
and Ka lbe g, 2021), sound localisa ion and possibly also o he isk o
hea ing p oblems.
Highly ele an is also how a child’s ac i i y pa e n and social
beha iou may a ec he exposu e and in ake (Lipina, 2016; Tul e e al.,
2016). Fo example, i has been shown ha p eschool child en a e
exposed o signi ican ly highe noise le els as compa ed o hei p e-
school eache s - a di e ence amoun ed o as much as 6 o 8 dB
LAeq indoo s
o e he day (Pe sson Waye and Ka lbe g, 2021). This di e ence is mos
likely explained by se e al ac o s such as se e al child en being in one
oom, playing close o each o he also du ing loud ac i i ies and no
ha ing he capaci y o con ol, an icipa e, unde s and o cope wi h he
noise (Pe sson Waye e al. 2013, 2019). The need o child ele an
assessmen me hods in gene al is e iden and is speci ically o noise
exposu e cu en ly an issue o esea ch (Loh e al., 2022). Wi h a ew
excep ions, cu en heal h amewo ks do no deal wi h hese
age-speci ic aspec s well.
As seen in Fig. 2, examples o ex e nal and in e nal exposu es and
K. Pe sson Waye e al.
En i onmen al Resea ch 239 (2023) 117279
8
Fig. 2. Rele an dimensions o he exposome concep ualisa ion, such as places, exposu es, ac o s, ac i i ies, social p ac ices and li e s ages, emphasizing hei
in e ela ionships. Social p ac ice is seen as an unde lying and modi ying concep ha a ec s and is a ec ed by he di e en componen s. Inhe i ed in he places a e
o a ious ex en s, aspec s o he exposu e domains used in Equal-Li e (indoo and ou doo en i onmen al quali y, na u al en i onmen , buil en i onmen , social
en i onmen and li es yle). The in e nal exposu es (e.g., p o eins and me aboli es) a e in his concep less well ied o place bu may s ill be a ec ed by he social
p ac ices and he li e cou se. The li e cou se highligh s he need o conside he child de elopmen as a c ucial aspec in he a icula ion o he social p ac ices and he
exposu es in connec ion o he places, ac o s and ac i i ies.
K. Pe sson Waye e al.
En i onmen al Resea ch 239 (2023) 117279
9
combina ions a e po en ially ele an o a child’s men al heal h and
cogni ion. A p elimina y lis o ele an exposu es o child en was
p esen ed by an Kamp e al. (2022) and his was ex ended du ing he
cou se o he p ojec , using he domains: indoo and ou doo en i on-
men al quali y, na u al en i onmen , buil en i onmen , social en i-
onmen and li es yle. In he p e iously men ioned li e a u e e iew o
how sleep, psychophysiological s ess, and sel - egula ion/coping (pa-
pe s in p epa a ion) and es o a ion (Dzambo e al., 2023), may
media e he associa ion o exposome and men al heal h, p elimina y
analyses show ha physical and social exposu es, we e mos equen ly
included in he exposome, while in e nal exposu es we e less commonly
conside ed. Physical exposu es included: ou doo and indoo en i on-
men al quali y (i.e., noise, ai pollu an s inclusi e passi e obacco
smoke, and es o a i e g een and blue a eas), li es yle (i.e., die ,
smoking, sc een ime and physical ac i i y) and buil en i onmen
(u ban/ u al). O he social exposu es, socioeconomic (i.e., household o
pa en al income, pa en al educa ion), social ci cums ances (i.e.,
c owding, social cohesion, child sepa a ion, e hnic mino i y), psycho-
social mechanisms (i.e., ad e se ca egi e -child in e ac ion, abuse,
amily hos ili y, pa en men al illness, pa en ing) and combined ac o s
(i.e., s ess ul li e e en s, ad e se childhood expe iences) we e mos
o en epo ed. In e nal exposu es classi ied wi hin he g oups: me ab-
olomics (e.g se o onin), p o eomics (e.g cy okines), epigene ics (e.g
me hyla ion changes) as well as ansc ip omics and mic obiome, we e
mainly epo ed o he s udies on s ess.
This pape has hough no ambi ion o p o iding an exhaus i e lis o
exposu es bu a he o p opose a amewo k o how o app oach hese.
Some o hese exposu es a e as shown in Fig. 2 based on li e-cou se
phase, place, and social p ac ices, which should be iewed in ela ion
o ac o s and ac i i ies.
In addi ion, he exposu es may di e be ween u ban and u al se -
ings and be ween di e en cul u es and coun ies. In ecen yea s he
u ban en i onmen (ci y-le el) and i s places a e commonly iden i ied as
being o pa icula isk o heal h. Fac o s ela ed o u banisa ion, such
as apid g ow h, a high densi y o people, buildings and anspo , lack
o social cohesion, c iminali y, high demand on d inking wa e supplies
and sizeable was e handling, highligh he isks o an unheal hy en i-
onmen (e.g., Fi daus and Ahmad, 2014). Howe e , ocusing on u -
bani y discoun s a ound 43% o he global popula ion and ends o
igno e he ele ance o an exposome pe spec i e in u al a eas,
including hose ad e se o child en’s heal h (e.g., chemical exposu es
om a ming, acciden s a a ms, noise om anspo a ion, unsa e o
long anspo a ion o schools and leisu e ac i i ies, lack o choice o
educa ion, poo accessibili y o heal h ca e and inequali y in SES).
Impo an ly, po en ial salu ogenic exposu es also di e , such as access
o g een and blue a eas, places o playing and physical ac i i y, and
social cohesion in smalle communi ies. Al hough, da a om he US
epea edly desc ibe how child en in u al a eas a e a pa icula isk o
hei heal h and well-being (US Census Bu eau, 2008; Che y e al.,
2007), a mo e complex pic u e is p esen ed in a Uni ed Na ion epo
(UN, 2018) co e ing a global pe spec i e. When analysing se e al in-
dica o s o child well-being in 77 coun ies (mos ly low and
middle-income coun ies), i con i ms on he one side ha u ban chil-
d en in mos coun ies a e be e han u al child en, bu ha he ig-
u es also hide huge inequali ies in u ban a eas. One o he ew s udies
ha in es iga ed cumula i e isks o child en in u al a eas co e-
sponded wi h conclusions om s udies in u ban a eas ha cumula i e
isks inc eased psycho-social dis ess and showed an associa ion wi h a
lowe a ing o sel -wo h (E ans, 2003). Taken oge he , a gene al
conclusion is ha ew s udies ha e unde aken an exposome pe spec i e
o s udy child en’s heal h in u al a eas. An impo an ques ion when
p omo ing child en’s heal h globally is whe he in e en ions ailo ed
o he u ban en i onmen also a e applicable o app op ia e o he
u al en i onmen . This ques ion needs u he s udy.
Simila ly, a be e unde s anding and inclusion o a global pe spec-
i e a e called o , as he e a e ew s udies p o iding his in o ma ion.
We ha e come o ealise ha ou unde s anding o he exposome
pe spec i e ega ding child en is based on high and middle-income
coun ies and is aken om geog aphically es ic ed a eas o he
globe. A global pe spec i e on exposu e, i s dis ibu ion and i s iming as
well as social suppo and indi idual esilience a e needed o place
child en and adolescen s a he cen e o he sus ainable de elopmen al
goals “ o cu en and u u e gene a ions” (Al ´
en e al., 2019).
5. The concep ual amewo k
In Fig. 3 we p esen a concep ual amewo k on exposome, men al
heal h, well-being and cogni i e de elopmen in child en and adoles-
cen s, including po en ial media o s (Fig. 3). Wi h media o s, we e e o
a iables ha may link he exposome o men al heal h/cogni i e
de elopmen . O main ocus in Equal-Li e was he media o s: sleep,
psychophysiological s ess, es o a ion and sel - egula ion/coping and
how hey po en ially media ed he linkage o exposome o men al heal h
and cogni i e de elopmen . These esul s a e published sepa a ely (e.g.
Dzhambo e al., 2023) in his special issue.
The de elopmen o he amewo k was based on an in e ac i e
esea ch p ocess, oscilla ing om induc i e and deduc i e easoning,
conside ing he indings o li e a u e e iews in connec ion wi h u he
e idence, exis ing models (e.g., Dahlg en and Whi ehead, 1991; Ins i-
u e o Medicine, 2000; K iege , 2012), p e ious wo k o Equal-Li e
(Gudi-Minde mann e al., 2023) and in e disciplina y expe ise discus-
sions wi hin and ou side he Equal-Li e amewo k.
In Fig. 3, ‘Exposome’ depic s he en i onmen in which he indi-
idual is embedded includes social, physical and in e nal exposu es (see
also Sec ion 3) and ha a e expec ed o change and inc ease in
complexi y along he li e cou se (Wild, 2005, 2012; Senie e al., 2017).
The social, physical and in e nal exposu es in e ela e along he li e
cou se, no as sepa a e pa s o he en i onmen bu as he o al en i-
onmen in i sel , o he exposome. The ela ionships be ween expo-
some, media o s and ou comes a e magni ied in he cen e o his
amewo k and should be unde s ood as embedded in he en i onmen
along wi h he indi iduals. The exposome in e links wi h he media o s
o a ec men al heal h and cogni ion and p o ides a possibili y o in-
e en ions along he li e cou se. Men al heal h and cogni i e de elop-
men also in e ac wi h each o he in a bidi ec ional mode as depic ed by
he a ows in he igu e and as p e iously no ed in Sec ion 2.
A balance is p oposed be ween he exposome and he men al
heal h/cogni i e de elopmen ou comes which is illus a ed in he o m
o a seesaw. The balance in oduces g aphically he no ion ha physical,
social and in e nal exposu es may ha e bo h de imen al and suppo i e
quali ies o e he li e cou se. I also ep esen s he no ion ha he ou -
comes a y om posi i e o nega i e. The media o s, in he middle,
con ey he mechanis ic, media ing ole o po en ial media o s and he
possibili ies o hese media o s o unc ion as con ibu ing ac o s in he
balance be ween en i onmen and heal h.
‘Vulne abili y’ (Fig. 3) is in ended o cap u e bo h he e ol ing
biological suscep ibili y in di e en phases o indi idual human de el-
opmen and a popula ion pe spec i e wi h a h ee-dimensional
app oach o ulne abili y comp ising 1) di e en ia ion o exposu e, 2)
di e en ia ion o e ec (i.e., suscep ibili y); and 3) di e en ia ion in
capaci y o espond o exposu e o heal h ad e si ies. As discussed in
Sec ion 4, i is impo an o no e ha hese dimensions a e no s a ic bu
luid in se e al espec s. A li e-cou se exposu e implies ha p ena al o
an ena al exposu es may induce suscep ibili y o subsequen exposu es.
Consequen ly, social pa e ns (e.g., due o socioeconomic posi ion,
gende ) and unequal exposu es in child en and adolescen s migh also
esul in subsequen inequali ies in suscep ibili y. The ulne abili y
laye closely in e ac s wi h he o he laye s whe e “social s uc u es and
alues” ela e no only o unequal exposu es du ing childhood and
adolescence bu also o access o esou ces and he eby he capaci y o
espond o exposu es and ad e si ies. Simila ly, ulne abili y may be a
p oduc o social p ac ices by he child en hemsel es o o he ele an
K. Pe sson Waye e al.
