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Risk Factors For Autism. Perinatal Factors Parental Psychiatric History and Socioeconomic Status
Risk Factors For Autism. Perinatal Factors Parental Psychiatric History and Socioeconomic Status
Risk Factors For Autism. Perinatal Factors Parental Psychiatric History and Socioeconomic Status
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Copyright ª 2005 by the Johns Hopkins Bloomberg School of Public Health Printed in U.S.A.
All rights reserved DOI: 10.1093/aje/kwi123
ORIGINAL CONTRIBUTIONS
Risk Factors for Autism: Perinatal Factors, Parental Psychiatric History, and
Socioeconomic Status
Received for publication February 6, 2004; accepted for publication August 11, 2004.
Research suggests that heredity and early fetal development play a causal role in autism. This case-control study
explored the association between perinatal factors, parental psychiatric history, socioeconomic status, and risk of
autism. The study was nested within a cohort of all children born in Denmark after 1972 and at risk of being diagnosed
with autism until December 1999. Prospectively recorded data were obtained from nationwide registries in Denmark.
Cases totaled 698 children with a diagnosis of autism; each case was individually matched by gender, birth year, and
age to 25 controls. Analyses by conditional logistic regression produced risk ratios and 95% confidence intervals.
Adjusted analyses showed that the risk of autism was associated with breech presentation (risk ratio (RR) ¼ 1.63,
95% confidence interval (CI): 1.18, 2.26), low Apgar score at 5 minutes (RR ¼ 1.89, 95% CI: 1.10, 3.27), gestational
age at birth <35 weeks (RR ¼ 2.45, 95% CI: 1.55, 3.86), and parental psychiatric history (schizophrenia-like
psychosis: RR ¼ 3.44, 95% CI: 1.48, 7.95; affective disorder: RR ¼ 2.91, 95% CI: 1.65, 5.14). Analyses showed no
statistically significant association between risk of autism and weight for gestational age, parity, number of antenatal
visits, parental age, or socioeconomic status. Results suggest that prenatal environmental factors and parental
psychopathology are associated with the risk of autism. These factors seem to act independently.
autistic disorder; fetal growth retardation; mental disorders; parturition; perinatology; pregnancy outcome
Abbreviations: ICD-8, International Classification of Diseases, Eighth Revision; ICD-10, International Classification of Diseases,
Tenth Revision; IDA, Integrated Database for Longitudinal Labour Market Research; MBR, Medical Birth Register; PCR,
Psychiatric Central Register.
Editor’s note: An invited commentary on this article munication and social interaction as well as restricted and
appears on page 926. repetitive interests and behaviors. Included are autistic
disorder (infantile autism), pervasive developmental disor-
der–not otherwise specified, and Asperger’s disorder. The
Autism spectrum disorders are a group of pervasive term ‘‘autism’’ is often used to refer to autistic disorder,
developmental disorders characterized by impaired com- which affects approximately one to two children per 1,000
Reprint requests to Dr. William W. Eaton, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University,
624 North Broadway, Baltimore, MD 21205 (e-mail: weaton@jhsph.edu).
(1–5). The prevalence of autism spectrum disorders as assigned to all residents in Denmark. This number is used in
a whole may range from two to six per 1,000 (2, 3, 5, 6). The all contacts with authorities and by all national registers, which
etiology of these disorders is not completely understood, but ensures accurate and complete linkage between registers.
twin and family studies suggest that genetic factors play The PCR contains data on all admissions to Danish
a substantial causal role; the concordance rate is found to be psychiatric inpatient facilities since April 1969. In Den-
at least 36 percent for monozygotic twins and is expected to mark, inpatients include both patients who stay at the
be about 3 percent for dizygotic twins (7). However, a con- hospital overnight and patients who come to the hospital
cordance rate for monozygotic twins of less than 100 per- daily for evaluation and treatment. Information about out-
cent indicates that nongenetic factors also play a causal role. patient visits to psychiatric departments has been included
Prenatal exposure to valproic acid, thalidomide, rubella, and in the register since January 1, 1995. Until December 31,
alcohol has been associated with an increased risk of autism 1993, diagnostic information was coded according to the
spectrum disorders (8–11). World Health Organization’s International Classification of
Several studies have focused on perinatal risk factors for Diseases, Eighth Revision (ICD-8); since January 1, 1994,
Am J Epidemiol 2005;161:916–925
of being diagnosed with autism before the end of December was based on the gross income of each parent assessed at the
1999. The cases included all children (N ¼ 698, 167 girls, 531 child’s birth (birth after January 1, 1980) or in 1980 (when
boys, born in 1973–1994) discharged from a Danish psychi- the IDA was initiated). First, individual income was classi-
atric hospital with a diagnosis of infantile or atypical autism fied according to the year-, gender-, and age-specific (5-year
(ICD-8 diagnosis codes 299.00–299.01 or ICD-10 diagnosis groups) distribution of gross income based on a 5 percent
codes F84.0–F84.1x) before the end of December 1999. subsample of the IDA. The distribution quartiles determined
For each case, we identified 25 controls through the IDA the classification: highest, high-middle, low-middle, or
by means of incidence density sampling. The controls were lowest income. The wealth variable was defined according
individually matched to the cases by gender, birth year, and to the parent whose income was in the highest quartile.
age in days.
For all children, information about perinatal character- Data analyses
istics was obtained from the MBR. The children’s parents
were identified through the IDA; by linkage with the PCR, Data were analyzed by using conditional logistic re-
Am J Epidemiol 2005;161:916–925
TABLE 1. Gender, age at diagnosis, and diagnosis group for We found an increased risk of autism for children whose
infantile or atypical autism cases and associated controls birth weight was less than 2,501 g in general and less than
among all children born in Denmark after 1972 and at risk of 2,001 g in particular. When we restricted the analysis to
autism until the end of 1999 children born at term (37 weeks, 619 cases and associated
Cases Controls controls), the risk of autism remained higher for children
%
(n ¼ 698) (n ¼ 17,450) whose birth weight was less than 2,501 g (birth weight
Gender <2,001 g: risk ratio ¼ 4.35, 95 percent confidence interval:
Male 531 13,275 76.1
1.48, 12.77; birth weight 2,001–2,500 g: risk ratio ¼ 2.21,
95 percent confidence interval: 1.45, 3.36) compared with
Female 167 4,175 23.9
children whose birth weight was 3,001–3,500 g.
Age at diagnosis (years)
1–5 324 8,100 46.4
6–10 206 5,150 29.5 Parental psychiatric history and socioeconomic status
Am J Epidemiol 2005;161:916–925
TABLE 3. Distributions, unadjusted risk ratios, and 95% confidence intervals for perinatal risk factors,
parental psychiatric history, and socioeconomic characteristics among children born in Denmark after
1972 and at risk of autism until the end of 1999
Fetal presentation
Cephalic 620 88.8 16,364 93.8 Reference
Breech 58 8.3 851 4.9 1.80 1.36, 2.38
Other 5 0.7 54 0.3 2.44 0.97, 6.13
Missing 15 2.2 181 1.0
Apgar score at 5 minutesy
Table continues
Am J Epidemiol 2005;161:916–925
TABLE 3. Continued
Am J Epidemiol 2005;161:916–925
TABLE 4. Adjusted risk ratios and 95% confidence intervals for perinatal risk factors, parental psychiatric
history, and socioeconomic characteristics among children born in Denmark after 1977 and at risk of
autism until end of 1999
Model 1* Model 2y
RRz 95% CIz RR 95% CI
Fetal presentation
Cephalic Reference Reference
Breech 1.62 1.17, 2.24 1.63 1.18, 2.26
Other 1.86 0.57, 6.12 1.92 0.58, 6.36
Apgar score at 5 minutes
10 Reference Reference
8–9 0.85 0.59, 1.24 0.84 0.58, 1.23
1–7 1.97 1.15, 3.36 1.89 1.10, 3.27
* Adjusted model including all perinatal factors; each variable was controlled for all of the other variables in the model.
y Adjusted model including perinatal factors, parental psychiatric history, and socioeconomic characteristics; each variable was
controlled for all of the other variables in the model.
z RR, risk ratio; CI, confidence interval.
Am J Epidemiol 2005;161:916–925
Am J Epidemiol 2005;161:916–925
children of schizophrenic mothers are at increased genetic Medical Research Institute; and by National Institute of
risk of schizophrenia and neurodevelopmental impairment Mental Health grant MH53188.
(37, 38). The causal direction between autism and parental
affective disorder, substance abuse, or other mental illness is
less clear. Because genetic inheritance patterns may differ
for mothers and fathers, it would be ideal to consider
REFERENCES
psychiatric history of the mother and the father separately.
The number of affected parents was limited in this study, so 1. Gillberg C, Wing L. Autism: not an extremely rare disorder.
we were unable to consider parental differences related to Acta Psychiatr Scand 1999;99:399–406.
the risk of autism in the offspring. 2. Fombonne E. The epidemiology of autism: a review. Psychol
Genetic inheritance might be related to high parental age Med 1999;29:769–86.
(39). However, our adjusted results showed no increased 3. Yeargin-Allsopp M, Rice C, Karapurkar T, et al. Prevalence
risk of autism associated with high parental age. of autism in a US metropolitan area. JAMA 2003;289:
Am J Epidemiol 2005;161:916–925
prenatal, perinatal and postnatal factors. Pediatrics 1990;86: 32. Kaye JA, Mar Melero-Montes M, Jick H. Mumps, measles,
514–19. and rubella vaccine and the incidence of autism recorded by
22. Wolff S, Narayan S, Moyes B. Personality characteristics of general practitioners: a time trend analysis. BMJ 2001;
parents of autistic children: a controlled study. J Child Psychol 322:460–3.
Psychiatry 1988;29:143–53. 33. Wilcox AJ. On the importance—and the unimportance—of
23. Bennedsen BE, Mortensen PB, Olesen AV, et al. Preterm birth birthweight. Int J Epidemiol 2001;30:1233–41.
and intra-uterine growth retardation among children of women 34. Deykin EY, MacMahon B. Pregnancy, delivery, and neonatal
with schizophrenia. Br J Psychiatry 1999;175:239–45. complications among autistic children. Am J Dis Child
24. Bennedsen BE. Adverse pregnancy outcome in schizophrenic 1980;134:860–4.
women: occurrence and risk factors. Schizophr Res 1998; 35. Lord C, Mulloy C, Wendelboe M, et al. Pre- and perinatal
33:1–26. factors in high-functioning females and males with autism.
25. Munk-Jørgensen P, Mortensen PB. The Danish Psychiatric J Autism Dev Disord 1991;21:197–209.
Central Register. Dan Med Bull 1997;44:82–4. 36. Wolf S. Loners. The life path of unusual children. London,
26. Knudsen LB, Olsen J. The Danish Medical Birth Registry. United Kingdom: Routledge, 1995.
Am J Epidemiol 2005;161:916–925