Phthalate mixtures in pregnancy, autistic traits, and adverse childhood behavioral outcomes

Environ Int. 2021 Feb;147:106330. doi: 10.1016/j.envint.2020.106330. Epub 2021 Jan 5.


Background: Prenatal exposure to multiple phthalates is ubiquitous, and yet few studies have evaluated these exposures as a mixture in relation to child autistic traits and behavioral problems.

Objectives: To assess cumulative associations between prenatal phthalate mixtures and child behaviors, including effect modification by exposure timing and child sex.

Methods: Analyses included 501 mother/child pairs from the multicenter pregnancy cohort The Infant Development and Environment Study (TIDES). Nine maternal urinary phthalate metabolites were measured in early and late pregnancy, and behavior was assessed at ages 4-5 years using composite T scores for the Behavioral Assessment System for Children (BASC-2), which measures several dimensions of child behavior, and the Social Responsiveness Scale (SRS-2), which measures social impairment consistent with autistic traits. We utilized weighted quantile sum (WQS) regressions to examine pregnancy period-specific associations between phthalate mixtures and behavioral outcomes. Full-sample 95% WQS confidence intervals are known to be anti-conservative, so we calculated a confirmatory p-value using a permutation test. Effect modification by sex was examined with stratified analyses.

Results: A one-quintile increase in the early pregnancy phthalate mixture was associated with increased SRS-2 total score (coefficient = 1.0, confirmatory p = 0.01) and worse adaptive skills (coefficient = -1.0, confirmatory p = 0.06) in both sexes. In sex-stratified analyses, the early pregnancy phthalate mixture was associated with increased SRS-2 total score in boys (coefficient = 1.2, confirmatory p = 0.04) and girls (coefficient = 1.0, confirmatory p = 0.10) and worse BASC-2 adaptive skills score in girls (coefficient = -1.5, confirmatory p = 0.06), while the late pregnancy phthalate mixture was associated with increased BASC-2 externalizing score in boys (coefficient = 1.3, confirmatory p = 0.03).

Conclusion: Our results suggest cumulative adverse associations between prenatal phthalate mixtures and multiple facets of childhood behavior.

Keywords: Autism; Child behavior; Externalizing behavior; Mixture effects; Phthalates; Prenatal exposure.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Autistic Disorder*
  • Child
  • Child, Preschool
  • Environmental Exposure
  • Environmental Pollutants* / toxicity
  • Female
  • Humans
  • Infant
  • Male
  • Phthalic Acids* / toxicity
  • Pregnancy
  • Prenatal Exposure Delayed Effects*


  • Environmental Pollutants
  • Phthalic Acids
  • phthalic acid