Running Head: FOLIC ACID AND AUTISM

Folic Acid and the Risk of Autism

Jeanne Ventura
University of North Florida

Introduction:

FOLIC ACID AND AUTISM

Autism Spectrum Disorder (ASD) prevalence, according to Fombonne (2009), is 6 to 7 in

every 1,000 live births (.6%-.7%) significantly higher than what was originally thought. ASD is
characterized by poor communication and social skills as well as repetitive, restrictive interests
and behaviors (Barger, Campbell & McDonough 2012). Given the nature of Autism and the
consequences of this disorder, Fombonnes (2009) statistics are quite alarming. Studies show that
there are many different factors, including heredity, that cause a child to have Autism (Johnson,
Giarelli, Lewis, & Rice, 2012). Scientists are increasingly interested in the causes of ASD and
when it begins to develop. Recent studies have been done that show there is a strong connection
between the diet of the mother and how genes are expressed, the development of the nervous
system and the risk of disease later in life in the developing fetus (Meltzer, Brauntsaeter, Nilsen,
Magnus, Alexander & Haugen, 2011). This brings attention to the diet of and supplements taken
by the mother while pregnant and if that has anything to do with the risk of having a child with
ASD.
Folic acid has gained considerable attention because of the positive effects it has on
fetuses when taken as a supplement during pregnancy (Barua, Kuizon & Junaid, 2014). Folate
deficiency on the other hand has been linked to many birth defects (Barua, Kuizon & Junaid,
2014). Taking folic acid supplements while pregnant is beneficial in preventing neural tube
defects as well as spina bifida (Barua, Kuizon & Junaid, 2014). Not much is known about the
correlation between taking folic acid supplements during pregnancy and having a child with
ASD (Schmidt,et al. 2012). The causes and risk factors of ASD have been researched for years
and there are still not enough conclusions. The purpose of this review is to determine if there is a
relationship between the proper supplementation of folic acid during pregnancy and the risk of
having a child with ASD. Because of the positive effects of folic acid and the negative effects of

FOLIC ACID AND AUTISM

folate deficiency, there is a very strong possibility that the proper supplementation of folic acid
during pregnancy will reduce the risk of having an autistic child.
Findings:
There were five articles that were analyzed and of those articles three had positive
support for the supplementation of folic acid during pregnancy as a protective factor for reducing
the risk of having an autistic child. Schmidt, et al. (2012) did a retrospective study in which they
asked the mothers of children with ASD and mothers of the children of typically developed (TD)
children a series of questions about their diets during the periconception period of their
pregnancies. The periconception period of a pregnancy is approximately 4 weeks before
conception to 8 weeks after conception. Mothers with TD children reported higher intakes of
folic acid during the periconception period than those with children with ASD in this study.
Furthermore the authors concluded that increased folic acid intake during the periconception
period of pregnancy was positively associated with a decreased risk of ASD in children. This was
especially true in those who had folic acid intake at or above the recommended dosage (Schmidt,
et al., 2012). There were a few limitations in this study one of which was the retrospective nature
of the study itself (Schmidt, et al. 2012). When surveying women about their dietary intake while
they were pregnant over a year after they were pregnant introduced reporting bias, they might not
have remembered accurately what they consumed and how much folic acid they actually
consumed. Regardless of the limitations Schmidt, et al. (2012) contested that their findings still
indicate that sufficient amounts of folic acid during the first part of pregnancy may reduce the
risk of having a child with ASD.

FOLIC ACID AND AUTISM

What Schmidt, et al. (2012) found in their study is supported by the study done by Suren,
Roth, et al. (2013) in which they researched participants from the Norwegian Mother and Child
Study in which women were recruited during pregnancy, followed through pregnancy and after
birth followed their children and their development. Results that Suren, Roth, et al. (2013) found
that women who supplemented their diets with folic acid 4 weeks prior to conception through 8
weeks after conception had lowered risk of having a child with ASD. The main limitation of this
study was that not all cases of ASD in the cohort were reported due to drop outs (Suren, Roth, et
al. 2013). That being the largest limitation, this study shows a strong association between proper
consumption of folic acid and lowering the risk of ASD when consumed 4 weeks prior to
conception through 8 weeks after conception (Suren, Roth, et al. 2013).
Further support of these studies was found in the a study done by Suren, Schjolberg, et al.
(2014) in which participants were placed in the Autism Birth Cohort (ABC), these participants
were selected from the Norwegian Mother and Child Study for their potential to be ASD cases
and parents were administered questionnaires when their child was three, five and seven years
old. Participants were asked questions about their nutrition during pregnancy, early child growth,
etc. (Suren, Scjolberg, et al. 2014). When analyzing the results for maternal nutrition during
pregnancy the same trend was observed, those who consumed folic acid during the first 8 weeks
of pregnancy and the 4 weeks before conception were less likely to have a child with ASD
further supporting the importance of folic acid supplementation in early pregnancy (Suren,
Schjolberg, et al. 2014). These three studies provide a strong case for the positive association of
folic acid and the lowered risk of having a child with ASD at least when supplemented during the
periconception period.

FOLIC ACID AND AUTISM

In contrast, a study by Braun, et al. (2014) on the effects of folic acid supplementation
during the 2nd trimester of pregnancy found that there was little to no protective association
between folic acid supplementation and the risk of ASD. Braun, et al. (2014) believe that this is
due to the timing of folic acid supplementation, they only studied women who supplemented
their diets with folic acid during the last 6 months of their pregnancies rather than the first 3 or
before. This may seem to go against the findings of Schmidt, et al. (2012), Suren, Roth, et al.
(2013) and Suren, Schjolberg, et al. (2014) however, it actually supports the findings as the
critical time period identified by these studies is the before and during the first trimester of
pregnancy which was not studied here. By the time a woman is 3 months pregnant, it may be too
late for folic acid to help in preventing ASD as the nervous system is usually developed by then
(Schmidt, et al., 2012). Braun, et al. (2014) concluded that this period of development was not
affected by the intake of folic acid in reducing the risk of ASD.
Finally a study by Beard, et al. (2011) hypothesized that too much folic acid intake could
actually be a causal factor in ASD. Beard, et al. (2011) analyzed statistics from Rochester, MN in
which the rates of ASD increased 8.2 fold between the years of 1976-1997. This followed the
trend of the use of prescription prenatal vitamin usage in the same city (Beard, et al. 2011). The
data was limited however by the fact that the increased rates could be due to a multitude of
factors including but not limited to increased awareness leading to increased diagnosis, other
nutrients ingested, and prenatal alcohol or tobacco use (Beard, et al. 2011). The authors
themselves admitted that this trend similarity may represent an ecological fallacy and be
misleading (Beard, et al 2011). The sales of bicycles and the incidence of cancer may have
similar trends but that does not mean that the sales of bicycles has anything to do with cancer.
Beard, et al. (2011) did not find an association between folic acid supplementation and an

FOLIC ACID AND AUTISM

increased risk of ASD. This does not discount or go against the findings of Schmidt, et al.
(2012), Suren, Roth, et al. (2013) and Suren Schjolberg, et al. (2014). In fact, the fact that their
hypothesis that too much folic acid could actually cause ASD was not found to be accurate
actually supports the findings of the previous three studies.
Conclusion:
The purpose of this review was to examine whether or not the proper supplementation of
folic acid during pregnancy would reduce the risk of having a child with ASD. After assessing
the literature in this review the evidence suggests that the supplementation of folic acid during
the period of 4 weeks before conception through 8 weeks after conception is a protective factor
in reducing the risk of having a child with ASD. It is very important to note the time window that
folic acid was an effective protective factor as it was found that if women are already 3 months
pregnant folic acid was no longer a protective factor for reducing the risk of having a child with
ASD (Braun, et al. 2014). While these studies have proved to support the hypothesis of this
review, the timing of folic acid supplementation is very important and further research does need
to be done in order to bring more strength to these findings and to isolate other protective factors
to reduce the risk of ASD. While the evidence in this review was impressive, it was not without
limitations. One such limitation was the small amount of studies reviewed, had there been more
studies to analyze the findings would have been much more robust. Another inherent limitation
was the number of reviewers, as there was a single reviewer this introduced bias that was
unchecked.
Findings in this review are very important from a public health perspective as it could
change the recommendations for proper supplementation of folic acid among pregnant women

FOLIC ACID AND AUTISM

and in so doing could reduce the risk of ASD. These results demonstrate that women planning to
become pregnant should begin to take folic acid supplementations prior to becoming pregnant
and only continue through the first 8 weeks of pregnancy. Folic acid supplementation after the
first 8 weeks would not be detrimental but it would no longer affect the risk of ASD. Public
health practitioners would do well to study these findings and relay them to the populations they
serve in order to increase the probability that women would take folic acid prior to becoming
pregnant and during at least the first 8 weeks of pregnancy thereby, possibly, reducing the risk of
ASD in their children. If this were to become a common practice among pregnant women,
research should be done in future to monitor ASD incidence rates to prove effectiveness.
In conclusion, the findings of this review are very important and appear to support the
hypothesis that the proper supplementation of folic acid while pregnant reduces the risk of
having a child with ASD, however, only when consumed 4 weeks prior to conception through 8
weeks after conception. Even though this is the case and these findings are very exciting in
helping to understand this disorder, more research is needed to support those findings and to
isolate other protective factors for lowering the risk of ASD.

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