Autism Linked to Being Firstborn, Breech or Moms 35 and Older Giving Birth

Children who are firstborn or breech or whose mothers are 35 or older when giving birth are at significantly greater risk for developing an autism spectrum disorder, University of Utah School of Medicine researchers have reported in a new study with Utah children.

In the April 27, 2009, online issue of the journal Pediatrics, the researchers showed that women who give birth at 35 or older are 1.7 times more likely to have a child with an autism spectrum disorder (ASD), compared with women between the ages of 20-34. Children diagnosed with ASD also were nearly 1.8 times more likely to be the firstborn child, the researchers found.insert beginning span tag hereAlthough they didn't identify a causal relationship between breech births and autism, children diagnosed with the disorder were more than twice as likely to have been a breech presentation, meaning they were not born head first.

"The results of this study give us an opportunity to look more closely at these risk factors for children across the autism spectrum, and not only those diagnosed with autism," said first author Deborah A. Bilder, M.D., assistant professor of psychiatry. "This shows that further investigation of the influence of prenatal factors is warranted."

Autism is a complex brain disorder that impairs social, communicative, and behavioral development and often is characterized by extreme behavior.

Bilder and her colleagues in the U medical school's department of psychiatry and the Utah Department of Health examined the birth records of Utah children who had been identified as having an autism spectrum disorder in a 2002 epidemiological study by the U.S. Centers for Disease Control and Prevention (CDC). That study looked at 8-year-old children in Utah's three most populous counties--Salt Lake, Davis, and Utah--and used nationally accepted criteria for an ASD classification. The researchers compared birth records for children identified with an ASD with unaffected children born in those three counties in 1994. Of that group, 196 were identified with an ASD. Birth certificates were available for 132 of those children, and the researchers examined those records for possible prenatal, perinatal, and neonatal risk factors related to ASD.

Their investigation showed that the mother's age when giving birth (older than 34), breech presentation, and being firstborn were significant risk factors for the development of an ASD. The researchers also identified a small but significant relationship between the increased duration of education among mothers of those children.

Further investigation would be needed to understand how these three risk factors may relate to ASD. But a possible explanation for the correlation of firstborn children might be that parents are reluctant to have a second child if the first is diagnosed with ASD. A possible interpretation of increased risk associated with advanced maternal age is that changes in genes occurring over time may contribute to autism spectrum disorders. The association found between breech presentation and ASD most likely indicates a shared cause, such as neuromuscular dysfunction. The vast majority of children born breech, however, are healthy.

This study follows several from the University in recent years, which found that Utah has one of the highest autism spectrum disorder rates in the country (one in 133 Utah children has the disorder), helped indentify a gene that may predispose people to autism, and showed that Utah adults with autism have a better quality of life than those in other studies.

For the next step in their research, Bilder and her colleagues want to repeat this study, using a larger population of Utah 8-year-olds from subsequent birth years, to see if it replicates the results of the current study. They also may study the subset of children with breech presentation to determine whether they haven a genetic vulnerability that put them at increased risk for developing an autism spectrum disorder.

The study's other authors are Judith P. Zimmerman, Ph.D., research assistant professor of psychiatry; Judith Miller, Ph.D., associate professor of psychiatry; and William M. McMahon, M.D., chairman of the Department of Psychiatry.

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Lack of Food Variety Puts Kids with Autism at Risk for Poor Nutrition

The strong preference kids with autism have for certain foods places them at risk for nutritional deficiencies because their diets lack sufficient variety, according to research presented at this year's Pediatric Academic Societies meeting in Baltimore.

Researchers said screening children for the amount of variety of food in their diets may be a good clinical marker to predict which children might be at risk for nutrition problems. Kids with low food variety scores who are at risk could then be referred to dieticians or therapists to help them expand food choices and improve nutrition, said Michelle Zimmer, M.D., lead investigator and a pediatrician in the division of Developmental and Behavioral Pediatrics at Cincinnati Children's.insert beginning span tag hereThe study is one of two presented by Dr. Zimmer and colleagues this year at PAS that deal with autism, the second one showing that the red blood cells of children with autism have low levels of a fatty acid linked to cognitive function. This finding, the researchers report, warrants further research into how the low fatty acid levels may trigger biochemical changes in the brain linked to autism.

The team found that levels of docosahexanoic acid and total omega-3 fatty acids were significantly lower in the red blood cells of autistic children than in normally developing children. Omega-3 fatty acids are nutritionally important substances considered vital to the normal development of children.

Evidence of abnormal fatty acid metabolism in children with autism runs counter to at least one previous study that suggested no difference between normally developing and autistic children. The different results between studies may be explained by the current research focusing on an older group of children, Dr. Zimmer said.

"The fatty acid docosahexanoic is linked to other mental health issues, and this raises questions about whether there are functional issues in neural cells involving a deficiency of essential fatty acids," said Dr. Zimmer. "The main point of the study is we cannot rule that fatty acids are part of the story of what is going on with kids who have autism."

Dr. Zimmer said its possible older children with autism have had more time to use up their bodies' stores of omega-3 fatty acids and are unable to replenish those stores. The 21 children with autism in this study were between the ages of 3 and 18 years, as were the 20 age-matched normally developing children and 10 if their siblings who served as control subjects.

The research team is conducting a larger study with more children to verify its PAS findings. Dr. Zimmer said another study is also under design to give essential omega-3 fatty acids, such as docosahexanonic acid, to children with autism to see what impact it has on brain chemistry and/or the disorder.

Increasing foods rich in omega-3 fatty acids in the diets of autistic children has been suggested by some researchers as potentially beneficial, Dr. Zimmer said. Although doing so would not have a negative impact on the children, until studies are conducted it isn't known what affect, if any, it might have, she added. Also, given the findings of the previous study on the lack of food variety among kids with autism, augmenting their diets could be challenging.

Most of the 19 autistic children in the food study had much lower food variety scores in their diets than typically developing children. A majority of the children with autism also suffered from nutritional deficiencies. The researchers concluded children with autism and low food variety scores are at risk for mild and serious nutritional deficiencies.

Researchers participating in studies were from the division of Developmental and Behavioral Pediatrics and division of Neurology at Cincinnati Children's. Researchers from the department of Pathology at the University of Cincinnati participated in the study on food variety.

The PAS meeting is the largest international meeting focused on research in child health. It is sponsored by the American Academy of Pediatrics, the American Pediatric Society, the Society for Pediatric Research, and the Ambulatory Pediatric Association.

Cincinnati Children's Hospital Medical Center is one of America's top three children's hospitals for general pediatrics and is highly ranked for its expertise in digestive diseases, respiratory diseases, cancer, neonatal care, heart care and neurosurgery, according to the annual ranking of best children's hospitals by U.S. News & World Report. One of the three largest children's hospitals in the U.S., Cincinnati Children's is affiliated with the University of Cincinnati College of Medicine and is one of the top two recipients of pediatric research grants from the National Institutes of Health. For its achievements in transforming healthcare, Cincinnati Children's is one of six U.S. hospitals since 2002 to be awarded the American Hospital Association-McKesson Quest for Quality Prize (r) for leadership and innovation in quality, safety and commitment to patient care. The hospital is a national and international referral center for complex cases, so that children with the most difficult-to-treat diseases and conditions receive the most advanced care leading to better outcomes. Additional information can be found at www.cincinnatichildrens.org.

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Most Shared: Exercise Makes Kids Learn, Focus Better

"No Child Left Behind" resulted in limited opportunities for students to be physically active during the school day. That may soon change, if the results of a study suggesting the academic benefits of physical education classes, recess periods and after-school exercise is taken seriously by policy-makers.

"The goal of the study was to see if a single acute bout of moderate exercise - walking - was beneficial for cognitive function in a period of time afterward," said lead researcher Charles Hillman, director of the Neurocognitive Kinesiology Laboratory at Illinois.

Results of the study suggest that physical activity may increase students' cognitive control - or ability to pay attention - and also result in better performance on academic achievement tests.

From the articles:

As school districts across the nation revamped curricula to meet requirements of the federal "No Child Left Behind" Act, opportunities for children to be physically active during the school day diminished significantly.

Future mandates, however, might be better served by taking into account findings from a University of Illinois study suggesting the academic benefits of physical education classes, recess periods and after-school exercise programs. The research, led by Charles Hillman, a professor of kinesiology and community health and the director of the Neurocognitive Kinesiology Laboratory at Illinois, suggests that physical activity may increase students' cognitive control - or ability to pay attention - and also result in better performance on academic achievement tests. "The goal of the study was to see if a single acute bout of moderate exercise - walking - was beneficial for cognitive function in a period of time afterward," Hillman said. "This question has been asked before by our lab and others, in young adults and older adults, but it's never been asked in children. That's why it's an important question."

For each of three testing criteria, researchers noted a positive outcome linking physical activity, attention and academic achievement.

Study participants were 9-year-olds (eight girls, 12 boys) who performed a series of stimulus-discrimination tests known as flanker tasks, to assess their inhibitory control.

On one day, students were tested following a 20-minute resting period; on another day, after a 20-minute session walking on a treadmill. Students were shown congruent and incongruent stimuli on a screen and asked to push a button to respond to incongruencies. During the testing, students were outfitted with an electrode cap to measure electroencephalographic (EEG) activity.

"What we found is that following the acute bout of walking, children performed better on the flanker task," Hillman said. "They had a higher rate of accuracy, especially when the task was more difficult. Along with that behavioral effect, we also found that there were changes in their event-related brain potentials (ERPs) - in these neuroelectric signals that are a covert measure of attentional resource allocation."

One aspect of the neuroelectric activity of particular interest to researchers is a measure referred to as the P3 potential. Hillman said the amplitude of the potential relates to the allocation of attentional resources.

"What we found in this particular study is, following acute bouts of walking, children had a larger P3 amplitude, suggesting that they are better able to allocate attentional resources, and this effect is greater in the more difficult conditions of the flanker test, suggesting that when the environment is more noisy - visual noise in this case - kids are better able to gate out that noise and selectively attend to the correct stimulus and act upon it."

In an effort to see how performance on such tests relates to actual classroom learning, researchers next administered an academic achievement test. The test measured performance in three areas: reading, spelling and math.

Again, the researchers noted better test results following exercise.

"And when we assessed it, the effect was largest in reading comprehension," Hillman said. In fact, he said, "If you go by the guidelines set forth by the Wide Range Achievement Test, the increase in reading comprehension following exercise equated to approximately a full grade level.

"Thus, the exercise effect on achievement is not statistically significant, but a meaningful difference."

Hillman said he's not sure why the students' performance on the spelling and math portions of the test didn't show as much of an improvement as did reading comprehension, but suspects it may be related to design of the experiment. Students were tested on reading comprehension first, leading him to speculate that too much time may have elapsed between the physical activity and the testing period for those subjects.

"Future attempts will definitely look at the timing," he said. Subsequent testing also will introduce other forms of physical-activity testing.

"Treadmills are great," Hillman said. "But kids don't walk on treadmills, so it's not an externally valid form of exercise for most children. We currently have an ongoing project that is looking at treadmill walking at the same intensity relative to a Wii Fit game - which is a way in which kids really do exercise."

Still, given the preliminary study's positive outcomes on the flanker task, ERP data and academic testing, study co-author Darla Castelli believes these early findings could be used to inform useful curricular changes.

"Modifications are very easy to integrate," Castelli said. For example, she recommends that schools make outside playground facilities accessible before and after school.

"If this is not feasible because of safety issues, then a school-wide assembly containing a brief bout of physical activity is a possible way to begin each day," she said. "Some schools are using the Intranet or internal TV channels to broadcast physical activity sessions that can be completed in each classroom."

Among Castelli's other recommendations for school personnel interested in integrating physical activity into the curriculum:

* scheduling outdoor recess as a part of each school day;

* offering formal physical education 150 minutes per week at the elementary level, 225 minutes at the secondary level;

* encouraging classroom teachers to integrate physical activity into learning.

An example of how physical movement could be introduced into an actual lesson would be "when reading poetry (about nature or the change of seasons), students could act like falling leaves," she said.

The U. of I. study appears in the current issue of the journal Neuroscience. Along with Castelli and Hillman, co-authors are U. of I. psychology professor Art Kramer and kinesiology and community health graduate student Mathew Pontifex and undergraduate Lauren Raine.

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Most Shared: Teachers Failing at Sex-Ed

A study of sex education in Illinois public schools found that only 42 percent of sex education teachers passed the comprehensiveness test. The four basic topics required to be rated "comprehensive:" abstinence until marriage or older, HIV/AIDS, other sexually transmitted diseases, and contraception.

"For this study, we set the bar for comprehensiveness fairly low relative to what most medical and public health organizations recommend," said senior author Stacy Tessler Lindau, MD, "and one out of three programs failed to clear it."

Nearly two-thirds of 12th graders have engaged in sexual intercourse, and studies suggest that accurate knowledge can delay sexual debut and increase the use of condoms or other forms of contraception when adolescents do become sexually active.

From the article:

A study of sex education in Illinois public schools found that one out of three teachers did not meet a very forgiving definition of comprehensive instruction, researchers from the University of Chicago Medical Center report in the February 2008 issue of the journal Obstetrics and Gynecology.

Only 65 percent of teachers who responded to the survey covered the four basic topics required to be rated "comprehensive:" abstinence until marriage or older, HIV/AIDS, other sexually transmitted diseases, and contraception. When the researchers added a widely recommended fifth topic--where to get condoms, birth control and health related services--only 42 percent of sex education teachers passed the comprehensiveness test. The survey also found that 30 percent of the State's sex-education teachers had never received sex-education training, well above the national average of 18 percent. Although most teachers with training reported that they felt, "very comfortable" teaching adolescents about sex, only 56 percent of those who lacked such training said they felt as comfortable.

"For this study, we set the bar for comprehensiveness fairly low relative to what most medical and public health organizations recommend," said senior author Stacy Tessler Lindau, MD, assistant professor of obstetrics and gynecology and medicine at the University of Chicago, "and one out of three programs failed to clear it."

"Our children learn many of the skills they need to be healthy citizens and to take responsibility for their own health in school," she said. "That should include information about sexual aspects of health. Physicians who care for adolescents need to know what students are, or are not learning, in school in order to fill gaps caused by deficits in program content, quality and teacher training."

Previous studies showed that nearly two-thirds of 12th graders have engaged in sexual intercourse, and that accurate knowledge can delay sexual debut and increase the use of condoms or other forms of contraception when adolescents do become sexually active.

"Most parents support school-based sex education and teens regard it as an important source of information," Lindau said, "yet we found that several important health topics and skills are omitted, more often than not, from most Illinois public school sex-education criteria."

"Uninformed teens often become uninformed young adults," said second author Adjoa S. Tetteh, research assistant and a college peer sex educator. "Working with college students, I have witnessed this firsthand. Many students come to college with years of sexual experience, but are learning, for the first time, about effective ways to prevent STIs and unintended pregnancy."

The researchers used data collected by NORC, a survey research firm. NORC mailed self-administered questionnaires to 335 sex education teachers from 201 public middle and high schools in 112 Illinois school districts in the 2003-04 school year. Sixty-two percent of the teachers, representing 91 percent of schools, responded.

Teachers were asked which of 17 possible topics they taught and, if they omitted certain topics, to explain why. They were also asked about their training and how they would grade the sex education curriculum.

The researchers found that 93 percent of Illinois Schools offered sex education; seven percent did not.
The most frequently taught topics, covered by 96 percent of teachers, were HIV/AIDS and other sexually transmitted diseases. Almost 90 percent of teachers covered abstinence. Among those who taught abstinence, 57 percent emphasized that it was the "best alternative," 39 percent said it was the "only alternative," and four percent described it as "one alternative."

Practical skills--such as contraception, condom use, decision-making and communicating with a partner--and morally debated topics, such as abortion or sexual orientation, were among the least frequently taught. Teachers who had not received sex-education training were less likely to spend time on practical or morally debated topics.

Of the 17 topics, emergency contraception was mentioned least, taught by only 30 percent of teachers. Only 32 percent of teachers brought up homosexuality or sexual orientation, 34 percent taught how to use condoms, 37 percent taught how to use other forms of birth control, 39 percent discussed abortion and 47 percent taught students where to access contraception and sexual-health services.

The most common reason for omitting a topic was "not part of the curriculum." Those who omitted condom use, however, most often cited "school or district policy."

Teachers gave themselves the highest grades for instruction on reproductive basics and abstinence, with nearly four out of five ranking that part of the curriculum as good or excellent. About two-thirds gave themselves comparable grades for teaching their students about the emotional consequences of sex, dealing with pressures to have sex, or where to access contraception or services.

Although about half rated their instruction on how to use condoms or other forms of birth control as good or excellent, a quarter rated instruction on these topics average and a quarter rated them as poor or very poor.

"Although a recent study has called into question the effectiveness of abstinence-only sex education, the trend over the last ten years, supported by federal incentives, has been to emphasize abstinence and exclude information about contraception," said Lindau. "Given that a large number of young people are sexually active, we worry that such restrictive approaches leave students unprepared to prevent pregnancy and/or sexually transmitted diseases."

"In most cases," she added, "they are not even given access to information about how to talk about these issues or where to get help should they need it. Doctors need to be aware of this and should be proactive in initiating discussion about sexuality with parents and adolescents. Doctors may also be an important resource for providing teachers with medically accurate information and training."
"Our study provides important new data from the teachers' perspective," said study co-author Melissa Gilliam, associate professor and section chief of family planning and contraceptive research at the University of Chicago. "It supports other recent studies showing that large numbers of teens, especially low-income and youth of color, received no instruction about birth control methods before they first had sex."

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