Education

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Critical review
Mitochondrial physiology and autism spectrum disorder RE

Introduction
Recent studies have suggested that
mitochondrial dysfunction is relatively common in many children with
autism spectrum disorder (ASD) and
appears to be the most prevalent
metabolic disorder associated with
ASD. However, the exact prevalence
of mitochondrial disease in ASD is
not clear as the classic criteria for
diagnosing mitochondrial disease
in ASD appear to underestimate the
true prevalence. Indeed, the prevalence of biomarkers of mitochondrial
dysfunction and abnormal electron
transport chain function appears to
be high in ASD. In addition, recent
studies have uncovered novel forms
of mitochondrial dysfunction in
ASD that may not be readily recognized by classic diagnostic criteria.
This critical review provides a brief
overview of mitochondrial function
and its influence on other cellular
systems in the context of ASD. The
mitochondrias role in producing energy is complex and linked to other
metabolic systems. Mitochondrial
energy production is a result of the
tricarboxylic acid cycle, fatty-acid
oxidation and the electron transport
chain working in concert. The unique
architecture of the mitochondria
facilitates the function of these systems. The function and architecture
of the mitochondria for producing
energy with a special reference to the
source of biomarkers of mitochondrial dysfunction is reviewed. Nonenergy functions of the mitochondria including calcium
buffering,
* Corresponding author
Email: REFrye@uams.edu

rkansas Childrens Hospital Research

A
Institute, Little Rock, AR, USA
2
Rossignol Medical Center, Irvine, CA, USA
1

heat
production and apoptosis are
outlined. Interactions with other
systems, including the porphyrin
pathway, urea cycle and glutathione
metabolism, are also outlined, followed by a discussion of mitochondrial control and regulation. Finally,
the recommended algorithm for the
diagnosis of mitochondrial disorders
in children with ASD is discussed.
Conclusion
The mitochondrial is critically important in understanding the physiological abnormalities associated with
ASD. By providing details regarding
mitochondrial function, this critical
review aims to provide a better understanding of the importance of mitochondria as it is related to ASD.

Introduction

Mitochondria are complex subcellular organelles that are essential for

cellular function. The primary role of
the mitochondria is energy production. Thus, the number of mitochondria per cell is proportional to the
energy requirements of the cell. For
example, skin cells have several hundred mitochondria, whereas muscle
cells have several thousand mitochondria. However, mitochondria
have many roles aside from energy
production, and mitochondrial metabolism interacts with several other
critical cellular systems, potentially

influencing, and being influenced by,

these systems. In addition, regulation and control of mitochondria
is complex (Table 1). This critical
review provides an overview of mitochondrial function in the context of autism spectrum disorder.

Discussion

Mitochondrial medicine
Mitochondrial medicine is a relatively new and evolving field. Although
the clinical and histological features
of mitochondrial disease (MD) were
recognized in the 1960s, it was not
until 1988 that specific MD could be
linked to a causative genetic mutation1. From that point on, MDs have
primarily been described in reference
to their associated genetic alterations. However, as the wide variation
in the phenotypic presentation of MD
is being appreciated, it is becoming
clear that many cases of MD cannot
be simply linked to a single specific
causative genetic abnormality.

MD and ASD
Recent studies have suggested that
mitochondria are not functioning
properly in many children with ASD2
and in genetic diseases associated
with ASD3. Of the many metabolic
disorders associated with ASD, mitochondrial dysfunction appears to be
the most prevalent4. Table 2 lists the

Table 1 Important aspects of mitochondrial function

Mitochondrial
functions

Metabolic system that

Mitochondrial control
interact with mitochondria and regulation systems

Carbohydrate oxidation Porphyrin pathway

FAO
Urea cycle
ATP production
Glutathione metabolism
Calcium buffering
Apoptosis
Heat production
Inflammation

mtDNA
nDNA
Epigenetics
Membrane potential
regulation
Redox regulation
Regeneration

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

Abstract

Frye1*, D Rossignol2

Page 2 of 10

Critical review
Table 2 Mitochondrial disorders reported in ASD
Functional abnormalities
ETC deficiency in complex I, II, III, IV and V
Co-enzyme Q deficiency
FAO
Mitochondrial DNA abnormalities
A3243A>G: mitochondrial encephalopathy with lactic acidosis and seizures
(MELAS) syndrome
3397A>G: complex I
8363G>A, 10406G>A, 4295A>G: tRNA
Large-scale mtDNA deletions
DNA depletion
Novel mitochondrial abnormalities
Complex I overactivity
Complex IV overactivity
Abnormal supercomplex assembly
Unique acyl-carnitine abnormalities (short- and long- but not medium-chain
elevations)
cause
neurodegenerative events11.
The ability to assess this potential relationship is further obscured by the
lack of the differentiation between
true MD and mitochondrial dysfunction (refer to the next paragraph) in
ASD. Since the association between an
inflammatory/infectious trigger and
neurodevelopmental regression has
only been demonstrated in children
with MD, the same association may
not hold true for mitochondrial dysfunction.
Despite this interesting connection
between ASD and classically defined
MD, the proportion of children with
ASD and classically defined MD appears to be low. A recent meta-analysis found that 5% of children with
ASD met strict criteria for classic MD.
One of the major studies that this
prevalence estimate was based on
was a population-based prospective
study conducted in Portugal and the
Azores, making the validity of this estimate particularly strong12. The classic criteria for diagnosing MD relies
heavily on diagnosing genetic abnormalities, but genetic abnormalities
are only found in the minority of
cases of children with MD and ASD,
suggesting that the classic criteria for

diagnosing MD may underestimate

the number of ASD children with
mitochondrial dysfunction2. Studies
that have examined biomarkers for
MD suggest that the percentage of
children with ASD who have abnormal mitochondrial function may be
as high as 30% to 50%2,13. Furthermore, one study found that 80% of
ASD children
demonstrated lower
than normal electron transport chain
(ETC) function in lymphocytes14.
Interestingly, several studies have
pointed to novel forms of mitochondria dysfunction in ASD, including
ETC overactivity rather than deficiencies15,16, abnormalities in supercomplex assembly17 and unique elevations in acyl-carnitines associated
with ETC, tricarboxylic acid (TCA) cycle and glutathione abnormalities18.
These novel forms of mitochondrial
dysfunction would be missed by the
classic criteria for diagnosing MD, but
it is not clear that such forms of mitochondrial dysfunction should be categorized as classic MD. Thus, at this
point, it is uncertain if these novel
forms of mitochondrial dysfunction
associated with ASD are equivalent
to classic MD, or whether they represent a more widespread novel form

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

forms of mitochondrial dysfunction

that have been associated with ASD.
The suggestion that abnormalities
in carbohydrate metabolism could be
involved in ASD was first proposed
over 25 years ago when an unusual
high rate of lactic acidosis (a biomarker of MD) was noticed in a case series
of children with ASD5. Since then,
several other notable reports have
associated MD with ASD. In 2002, the
HEADD syndrome, an association of
hypotonia, epilepsy, autism and developmental delay, was described in
a series of ASD children with respiratory chain disorders6. Although this
association appears common in children with ASD and MD, the HEADD
acronym has never really been commonly applied clinically or in the research literature. More recently, the
association of MD and ASD with vaccines gained controversial attention.
In one case that received considerable notoriety, a girl with underlying
MD underwent rapid regression into
an ASD diagnosis following a febrile
episode induced by multiple vaccinations given on the same day7. This
connection between infectious/inflammatory triggers with ASD and MD
was further substantiated by a case
series of 28 children with ASD and
MD. Shoffner et al.8 found that 71%
of the children in this case series who
manifested regression into ASD regressed within 2 weeks of an episode
of fever greater than 101F. Interestingly in 33% of these cases, the fever
was associated with routine childhood vaccinations. This should not be
completely surprising as it is widely
believed that infections can result in
metabolic decompensation in some
children with underlying metabolic
disease such as MD9, and studies have
verified this association in children
with an underlying MD10. However,
the true prevalence of this association
is unknown. Many practitioners suggest v
accination as a way to prevent
severe illnesses and point to the fact
that, for the large majority of individuals with MD, vaccination does not

Page 3 of 10

Critical review

Mitochondrial structure
The double membrane of the mitochondrion creates two separate compartments, each of which has distinct
structure and functions.

Matrix
The matrix contains the majority of
the enzymes that are responsible for
primary functions of the mitochondria including TCA cycle and fattyacid oxidation (FAO) enzymes as well
as mitochondrial DNA (mtDNA) and
the enzymes and machinery necessary to transcribe and translate
mtDNA into proteins.
Mitochondrial functions
Although mitochondria are the
primarily powerhouse of the cell,
they serve several other important

functions such as calcium buffering and mediating programmed

cell death (also known as apoptosis). The important functions of the
mitochondria will be reviewed here.
Energy production
The pathways for energy production are outlined in Figure 1 and are
discussed in detail below.

Electron carriers between

mitochondrial metabolic reactions
Electrons are derived from the oxidation of carbohydrates and fatty acids

Outer membrane
The outer membrane encloses the
entire mitochondria and is made of
a phospholipid bilayer with integral
proteins called porins. Porins are
large channels that are permeable to
molecules of about 5,000 Da, allowing ions, nutrients and other important small molecules to pass through
the membrane.

Inner membrane
The inner membrane is a specialized membrane that is relatively
impermeable to most molecules. This
facilitates the ability of the ETC to create an electrochemical proton gradient across the inner membrane. Many
proteins reside in the inner membrane
such as the ETC and specialized transport proteins. The inner membrane
has a very high protein-to-phospholipid ratio and unique phospholipids,
such as cardiolipin, which help make
the inner membrane impermeable.
Cristae
The inner membrane is folded into
lamellae called the cristae. These
folds greatly increase the inner membrane surface area, allowing a greater
number of ETC complexes to exist in
the mitochondria and decreasing the
distance between the ETC complexes
and important enzymes that reside
in the matrix.

Figure 1:Energy production pathways of the mitochondria. Biomarkers for

MD are coloured red. Pyruvate dehydrogenase complex is divided into three
subunits: E1, pyruvate dehydrogenase; E2, dihydrolipoyl transacetylase; E3,
dihydrolipoyl dehydrogenase. TCA cycle contains multiple enzymes: CS, citrate
synthase; AC, aconitase; ID, isocitrate dehydrogenase; KD, -ketoglutarate
dehydrogenase; SS, succinyl-CoA synthetase; SD, succinate dehydrogenase; FM,
fumarase; MD, malate dehydrogenase. FAO requires the carnitine shuttle to bring
fatty acids into the mitochondrial matrix: CPT I, carnitine palmitoyltransferase;
CACT, carnitine-acylcarnitine translocase; CPT II, carnitine palmitoyltransferase
II. ETC is composed of five enzyme complexes bound to the inner membrane.
Complex II is also known as SD and contains several subunits. Subunit A of SD
catalyses succinate to fumarate, while subunits B/C/D of SD oxidize FADH2
in order to reduce coenzyme Q10. Two electron carriers, the reduced forms
of NADH and FADH2, carry electrons from TCA and beta-oxidation to the ETC
complexes.

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

of mitochondrial
dysfunction that
could be secondary to other, possibly
amenable, factors. Using a broader
criterion for diagnosing MD, such as
the Morava et al. criteria (refer to the
Conclusion section)19,20, could allow
for the diagnosis of these novel forms
of mitochondrial dysfunction as MD
but could also blur the line between
an important distinction of different
types of MD.

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Critical review

Carbohydrate oxidation
One of the main functions of the mitochondria is the oxidation of glucose, the main carbohydrate energy
source of the cells. Glucose is initially
metabolized by glycolysis to form
pyruvate.
Pyruvate
If the mitochondria are functioning adequately, pyruvate crosses the
mitochondrial membranes into the
matrix where it is metabolized into
acetyl-CoA through a complex of
three enzymes called the pyruvate
dehydrogenase complex. Abnormalities in pyruvate dehydrogenase
complex function are known to cause
childhood MD21 but, to date, have not
been reported in ASD. Pyruvate is an
important biomarker for diagnosing
MD. If the mitochondria are dysfunctional, the TCA cycle will slow or shut
down, resulting in a build-up of pyruvate. Two metabolites of pyruvate,
namely lactate and alanine, also build
up if pyruvate is elevated. These are
important biomarkers of MD.

Tricarboxylic acid cycle

The TCA cycle combines the two
carbon acetyl-CoA (derived from
pyruvate) with the four carbon oxaloacetate (a metabolite in the TCA
cycle). Through a series of reactions,
a total of two carbons are removed
and converted to CO2. The electrons
from these reactions are transferred
to two electron carriers, NADH and
FADH2. The TCA cycle comes full circle to reproduce oxaloacetate, which
is used in the next cycle. Dysfunction
of the mitochondria can slow down
or stop the TCA cycle. In such a case,
the metabolites of the TCA cycle can

build up in the form of organic acids that are biomarkers of MD. One
case series has specifically reported
dysfunction in the TCA cycle in ASD18.
FAO
Fatty acids are oxidized in the mitochondrial matrix. While short-chain
and medium-chain fatty acids can
freely diffuse across the mitochondrial membranes, long-chain fatty
acids (greater than 10 carbons in
length) require the carnitine shuttle.
Very long-chain fatty acids (greater
than 22 carbons in length) are initially oxidized in peroxisomes rather
than the mitochondria until they are
shortened to long-chain fatty acids.
One case series18 and one case report2 has specifically reported potential abnormalities in FAO pathways in
ASD.

Carnitine shuttle
Three enzymes facilitate the transportation of fatty acids into the m
atrix.
Carnitine palmitoyltransferase I (CPT
I), which sits on the outer mitochondrial membrane, transfers an acyl
group (the fatty acid) from acyl-CoA
to Carnitine, p
roducing an acyl-carnitine molecule. The acyl-carnitine
crosses the inner mitochondrial
membrane using the transporter
carnitine-acylcarnitine translocase.
Inside the mitochondrial matrix, the
acyl is transferred back to a CoA by
CPT II. Total carnitine and specific
acyl-carnitines are helpful biomarkers of mitochondrial dysfunction. Abnormalities in total carnitine as well
as acyl-carnitines have been reported
in ASD2,18.
Beta-oxidation
Fatty acids are oxidized in the matrix by a series of reactions that incrementally decrease the length of
the fatty acid by two carbons. Each
time a fatty acid is shortened, one
acetyl-CoA and one NADH and one
FADH2 are produced. This reaction
continues until only one acetyl-CoA
remains (for even-chain length fatty

acids) or until a propionyl-CoA remains (for odd-chain length fatty acids). Propionyl-CoA is further metabolized to succinyl-CoA so it can enter
the TCA cycle.

ATP production
Adenosine triphosphate (ATP) is
produced by the ETC. The majority of
reported cases of MD in ASD involve
dysfunction of the ETC2.

ETC
A series of five enzyme complexes oxidize the electron carriers NADH and
FADH2 to create ATP. Complexes I, III
and IV (collectively known as the supercomplex) pump protons from the
matrix into the intermembrane space.
mtDNA mutations potentially linked
to abnormal supercomplex assembly have been reported in relation to
ASD17. The electrochemical gradient
produced by pumping protons across
the membrane results in a proton motive force, which is u
tilized by complex
V (ATP synthase) to produce ATP from
adenosine diphosphate. Complex II
transfers electrons to the ETC electron
carrier c oenzyme Q10 (CoQ), which is
further utilized by complex III.
Electron carriers of the ETC
Two electron carriers are used to
transfer electrons between ETC
complexes.

Coenzyme Q and the Q cycle

Coenzyme Q10 carries electrons
from complex I and II to complex III.
A complicated sequence of oxidation
and reduction of CoQ, which is called
the Q cycle, occurs at complex III. In
brief, a reduced CoQ carrying two
electrons and two protons is joined
by another reduced CoQ derived
from the Q cycle to donate four electrons and four protons to complex
III. The protons are pumped into the
intermembrane space to increase the
proton gradient while two electrons
reduce cytochrome b and the other
two reduce the Rieske iron-sulphur
protein. The reduced cytochrome b is

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

through the TCA cycle and FAO, respectively. These electrons are transported to the ETC, the final common
pathway for producing energy, using
two electron carriers, the reduced
form of nicotinamide adenine dinucleotide (NADH) and flavin adenine
dinucleotide (FADH2).

Page 5 of 10

then used to reduce CoQ along with

two protons derived from the matrix. In this way, the Q cycle assists
complex III to indirectly pump protons across the inner mitochondrial
membrane. Lower than normal CoQ
(ubiquinone) concentrations have
been reported in children with ASD
as compared to control children2.
Cytochrome C
Cytochrome C carries electrons from
complex III to complex IV. The reduced Rieske iron-sulphur protein
in complex III reduces cytochrome C
which is oxidized by complex IV and
recycled. Cytochrome C also has an
important role in apoptosis.

Calcium buffering
Calcium is transported in and out of
the intermembranous space by the
voltage-dependent
anion-selective
channel VDAC1. The behaviour of this
channel is dependent on the mitochondrial membrane potential. Calcium fluxes into the intermembranous
space can stimulate ATP production.
Regulation of calcium metabolism by
the mitochondria is part of the mitochondria-associated endoplasmic
reticulum membrane, a structure in
which the mitochondria is tethered to
the endoplasmic reticulum by a special protein tethering complex. Calcium is critical for neurotransmitter release at synapses, and many different
types of calcium metabolism abnormalities have been reported in ASD22.
Apoptosis
Apoptosis, or programmed cell death,
occurs through non-mitochondrial
(extrinsic) and/or mitochondrial
(intrinsic) pathways. Two molecules
are released from the mitochondria
that influence cytosolic apoptosis
pathways. First, the mitochondrial
apoptosis-induced channel (MAC) in
the outer mitochondrial membrane
allows cytochrome C to leak into the
cytosol where it interacts with cellular regulators of apoptosis. Second,
an increase in the permeability of

the outer mitochondrial membrane

allows small mitochondria-derived
activator of caspases to be released
from the mitochondria where it
modulates apoptosis.
Heat production
Mitochondria, primarily in brown
adipose tissue, can produce heat,
instead of ATP, by allowing the inner membrane proton gradient to
leak through uncoupling protein 1
(UCP1).

Critical systems that interact with

the mitochondria
Many metabolic systems feed their
biochemical products into mitochondrial pathways and/or derive
their biochemical substrates from
mitochondrial pathways; thus, mitochondrial dysfunction can affect
non-energy-producing systems.

Porphyrin pathway
Porphyrins are aromatic heterocyclic macrocycles, which are best
known for their ability to hold metals within their ring. The best known
porphyrin complex is heme. Heme is
widely used in many critical enzymes
including cytochromes a, b and c,
which are components of ETC complex III and IV. Porphyrin production
occurs both inside and outside the
mitochondria and requires a special
transporter that is ATP dependent
(see Figure2A). Thus, mitochondrial
dysfunction can decrease porphyrin
production, which can further lead
to inadequate ETC function and a
further decrease in porphyrin production, resulting in a vicious cycle.
This may be an important area of
research as abnormalities in porphyrins23 appear to be associated with
ASD.

Figure 2:Interaction between the mitochondria and other important metabolic

systems. (a) The initial and final steps in the porphyrin pathway are located
in the mitochondria. One of the products of the porphyrin pathway, heme,
is essential for subunits of ETC complexes. (b) Portions of the urea cycle are
located in the mitochondria. Notably, function of the ornithine transporter is
dependent on the inner mitochondrial membrane potential. (c) Generation
of glutathione de novo requires ATP, which is derived from the mitochondria.
Mitochondria are dependent on glutathione for redox regulation.

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

Critical review

Page 6 of 10

Urea cycle
The urea cycle maintains the concentration of the toxic ammonium ion in
a narrow, tolerable range by converting ammonia into urea, which can be
excreted by the kidney. The urea cycle resides partially in the mitochondria matrix (see Figure 2B). Transportation of ornithine, one of the key
amino acids in the urea cycle, across
the inner mitochondrial membrane is
dependent on the proton gradient. A
reduction in the inner mitochondrial
membrane potential, as occurs with
ETC dysfunction, limits the ability of
ornithine to be transported across
the inner mitochondrial membrane.
Increased ammonia is toxic and has
been reported in some individuals
with MD and also in individuals with
ASD2. Urea cycle disorders have been
reported in only a few cases of ASD4.
Glutathione metabolism
Glutathione is important for maintaining the normal redox state by
eliminating reactive oxygen and nitrogen species. As mitochondria are
the source of these toxic species,
proper mitochondrial function is dependent on glutathione. Glutathione
cannot be made in the mitochondria
but is rather transported into the mitochondria from the cytosol through
a special carrier. The production of
glutathione requires ATP. Thus, mitochondrial dysfunction can reduce
the ability of the cell to produce
new glutathione, thus leaving the
mitochondria vulnerable to reactive
species, some of which it produces
itself (see Figure 2C). Abnormalities
in glutathione metabolism have been
frequently r eported in children with
ASD24.
Mitochondrial control and
regulation
Mitochondrial DNA
Mitochondria have their own DNA,
which provides genetic information
to produce several ETC subunits; the
remaining ETC subunits are coded by
nuclear DNA (nDNA) (Table 3). Many

Figure 2:(Continued)

MDs, particularly those that are common in adults, have been linked to
abnormalities in genes in the mtDNA. A minority of children with ASD
and MD have been reported to have
abnormalities in mtDNA2.
The existence of mtDNA has several consequences. First, a separate system for translation and
transcription of mtDNA genes into
proteins is needed for the mitochondria. Some components of this
separate system are also coded for
by mtDNA. Because this system is
not as robust as the nuclear system,
mtDNA is much more vulnerable to

intrinsic and extrinsic factors that

cause mutations. Second, since mitochondria are inherited through
maternal cell lines (specifically the
ovum), MD does not follow a pattern
of Mendelian inheritance. In addition, only some of the mitochondria
inherited may m
anifest abnormal
mtDNA, leading to heteroplasmy.
This may result in only one portion
of the body or one organ system being affected by MD.
nDNA and epigenetics
In addition to the genetic information in mtDNA, 1500 or more nu-

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

Critical review

Page 7 of 10

Critical review

Mitochondrial membrane potential

The inner mitochondrial membrane
potential results from the proton
gradient created by the ETC. Large
electrochemical gradients can be associated with increased oxidative
stress. At least two mechanisms are
used to reduce this oxidative stress:
calcium fluctuations and uncoupling
proteins (UCP1, UCP2, UCP3), which
allow protons to leak across the inner
mitochondrial membrane
without
going through complex V.

Mitochondrial quality control

Mitochondria can reproduce, regenerate and terminate through
the processes of fission, fusion and
autophagy. These processes are
important for controlling the quality of mitochondrial function. For
example, mitochondria with abnormal mtDNA can combine with
mitochondria without such abnor
malities to reduce the influence of
such abnormalities26.
Diagnosing and treating MD
The workup for MD can be quite
complex27,28. One recent review has
outlined an evaluation algorithm
for children with ASD2 (Figure 3).
The findings from this workup

et al.19 suggest an MDC score 3

as criterion for performing a further workup, including a muscle biopsy, in order to confirm a
diagnosis of MD.
It is believed that there are no clear
cures for MD but with
supportive
treatment, the usual downhill course
associated with MD may be mitigated, and it is possible that recovery from the neurodevelopmental
effects of MD may be somewhat

can be used in association with

the Morava et al. criterion19. The
Morava et al. criterion is based on
several objective clinical, histological, biochemical, molecular, neuroimaging and e nzymatic findings
(Table 4). The likelihood of an MD
can be determined by the MD criteria (MDC) score. An MDC score predicts MD as: not likely (1), possible
(24 points), probable (57 points)
or definite (8 points). Morava

Table 3 Origin of genes for ETC complex subunits

ETC complex

nDNA subunits

mtDNA subunits

38

II

III

10

IV

10

14

Figure 3:Recommended algorithm for the metabolic workup of patients with

ASD. First, patients are screened with biomarkers of abnormal mitochondrial
function in the fasting state. Abnormalities may need to be verified with repeat
testing. For patients with biomarkers that point to an FAO defect, other disorders
of fatty-acid metabolism may need to be ruled out before further workup for
a mitochondrial disorder is conducted. Patients with consistent biomarkers
for mitochondrial dysfunction may initially be investigated for genetic causes
before a muscle and/or skin biopsy is considered.

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

clear genes control mitochondrial

function. These include genes encoding ETC complexes, membrane
transporters, FAO and TCA enzymes as well as genes for mtDNA
replication and maintenance, mitochondrial quality control and ETC
complex assembly. Mitochondria
play a critical role in controlling
nuclear genes through epigenetics. Products and metabolites derived from mitochondria, including ATP, acetyl-CoA and reducing
equivalents, modulate cytosolic
and nuclear pathways that control
nuclear gene activity25. Because
nDNA is involved in some portions
of mitochondria function, some
forms of MD may exhibit Mendelian
inheritance.

Page 8 of 10

Critical review
Table 4 Diagnostic worksheet for MD
Section I: Clinical signs and symptoms
(a) Muscular presentation (points)
Ophthalmoplegia (2)
Exercise intolerance (1)

Facies myopathica (1)

Rhabdomyolysis (1)

Abnormal EMG (1)

Muscle weakness (1)
Total Points I(a): (maximum score 2 points)

(b) CNS presentation (points)

Developmental delay (1)
Loss of skills/regression (1)
Seizures (1)
Extrapyramidal signs (1)

Pyramidal signs (1)

Stroke-like episodes (1)
Migraine (1)

Brainstem dysfunction (1)

Cortical blindness (1)
Myoclonus (1)
Total Points I(b): (maximum score 2 points)

(c) Multisystem disease (points)

Haematology (1)
GI tract (1)
Endocrine/growth (1)

Recurrent/familial (1)
Heart (1)
Hearing (1)

Vision (1)
Kidney (1)
Neuropathy (1)

I(a) + I(b) + I(c) Total points Section I: (maximum score 4 points)

Section II: Metabolic/imaging studies (points)
Elevated lactate (2)/alanine (2)
Elevated lactate/pyruvate ratio (1)
Urinary tricarbon acid excretion (2)
Ethylmalonic aciduria (1)

Elevated CSF lactate (2),

protein (1), alanine (2)
Stroke-like MRI picture on MRI (1)
Leigh syndrome on MRI (2)
Elevated lactate on MRS (1)
Total points Section II: (maximum score 4 points)

Section III: Morphology from muscle biopsy (points)

Reduced succinic dehydrogenase staining (1)
Abnormal mitochondria on electron microscopy (2)
Reduced cytochrome oxidase staining (4)
Ragged red/blue fibres (4)
Cox-negative fibres (4)
Succinic dehydrogenase-positive blood vessels (2)
Total points Section III: (maximum score 4 points)
Total score (I + II + III): (maximum score 12 points)
Interpretation:

1: Unlikely

24: Possible

57: Probable

812: Definite

This worksheet, which is based on the Morava et al. criterion, can be used to diagnose MD. The points from Section I: Clinical signs and symptoms, Section II:
Metabolic/imaging studies and Section III: Morphology from muscle biopsy are added together; the total provides a probability of a diagnosis of MD.

alleviated. Treatment for MD is focused on four strategies11,29. First,

precautions must be implemented to
prevent metabolic decompensation

and further developmental regression. This involves avoiding environmental triggers (such as environmental toxicants) and
medications

that are known to be harmful to the

mitochondria as well as avoiding illness, dehydration and fever. Second,
supplementation with specific vitamins can help support mitochondrial
function. These include carnitine,
CoQ, B vitamins, vitamin C and vitamin E as well as antioxidants. Third,

in some cases, the diet can be modified to optimize mitochondrial function. Some have found that diets such
as a ketogenic diet or a modified Atkins diet can be helpful. Last, common secondary effects of MD such
as gastrointestinal disturbances,
thyroid dysfunction, cerebral folate

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Frye RE, Rossignol D. Mitochondrial physiology and autism spectrum disorder. OA Autism 2013
Mar 01;1(1):5.

Competing interests: none declared. Conflict of interests: none declared.

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

Total Points I(c): (maximum score 3 points)

Page 9 of 10

deficiency and seizures should be

addressed to o
ptimize health.

Conclusion

Mitochondrial dysfunction
and ASD
It appears that mitochondrial dysfunction, rather than classic MD,
is more prevalent in children with
ASD. Children with mitochondrial
dysfunction may have a very different developmental trajectory than
children with classic MD, especially
if the mitochondrial dysfunction is
secondary to an amendable factor.
For example, the mitochondrion is
an adaptable organelle which can
modify its function depending on the
intracellular and extracellular environment. Specific conditions could
be inhibiting the function of the mitochondria in some children with ASD,
causing them to be dysfunctional. If
this is the case, changing the intracellular and extracellular environment
may restore mitochondrial function,
at least theoretically. In addition, the
mitochondrion is capable of repair
and regeneration. In the absence of a
genetic defect, it is possible that the
function of the mitochondria could
be restored by these repair mechanisms, and it might be possible in the
future to enhance these repair mechanisms. Although we are just beginning to understand the significance
of mitochondrial dysfunction and MD
in children with ASD, this new understanding of the molecular mechanisms associated with ASD provides
a pathway for discovering new treatments. In fact, several studies have
now reported clinical improvements
in children with ASD using certain
treatments that may target the mitochondria such as certain antioxidants, vitamins and minerals2,11,30.

Abbreviations list

ASD, autism spectrum disorder; ATP,

adenosine triphosphate; CoQ, coenzyme Q10; CPT, carnitine palmitoyltransferase; ETC, electron transport chain; FADH2, flavin adenine

inucleotide; FAO, fatty-acid oxidad

tion; HEADD, hypotonia, epilepsy, autism and developmental delay; MAC,
mitochondrial
apoptosis-induced
channel; MD, mitochondrial disease;
MDC, MD criteria; mtDNA, mitochondrial DNA; NADH, nicotinamide adenine dinucleotide; nDNA, nuclear
DNA; TCA, tricarboxylic acid; UCP,
uncoupling protein

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All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

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Mar 01;1(1):5.

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All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

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