The cerebral folate receptor alpha (FRα) transports 5-methyltetrahydrofolate (5-MTHF) into the brain; low 5-MTHF in the brain causes cerebral folate deficiency (CFD). CFD has been associated with autism spectrum disorders (ASD) and is treated with d,l-leucovorin (folinic acid). One cause of CFD is an autoantibody that interferes with the function of the FRα. FRα autoantibodies (FRAAs) have been reported in ASD. A systematic review was performed to identify studies reporting FRAAs in association with ASD, or the use of d,l-leucovorin in the treatment of ASD. A meta-analysis examined the prevalence of FRAAs in ASD. The pooled prevalence of ASD in individuals with CFD was 44%, while the pooled prevalence of CFD in ASD was 38% (with a significant variation across studies due to heterogeneity). The etiology of CFD in ASD was attributed to FRAAs in 83% of the cases (with consistency across studies) and mitochondrial dysfunction in 43%. A significant inverse correlation was found between higher FRAA serum titers and lower 5-MTHF CSF concentrations in two studies. The prevalence of FRAA in ASD was 71% without significant variation across studies. Children with ASD were 19.03-fold more likely to be positive for a FRAA compared to typically developing children without an ASD sibling. For individuals with ASD and CFD, meta-analysis also found improvements with d,l-leucovorin in overall ASD symptoms (67%), irritability (58%), ataxia (88%), pyramidal signs (76%), movement disorders (47%), and epilepsy (75%). Twenty-one studies (including four placebo-controlled and three prospective, controlled) treated individuals with ASD using d,l-leucovorin. d,l-Leucovorin was found to significantly improve communication with medium-to-large effect sizes and have a positive effect on core ASD symptoms and associated behaviors (attention and stereotypy) in individual studies with large effect sizes. Significant adverse effects across studies were generally mild but the most common were aggression (9.5%), excitement or agitation (11.7%), headache (4.9%), insomnia (8.5%), and increased tantrums (6.2%). Taken together, d,l-leucovorin is associated with improvements in core and associated symptoms of ASD and appears safe and generally well-tolerated, with the strongest evidence coming from the blinded, placebo-controlled studies. Further studies would be helpful to confirm and expand on these findings.


  • Autism spectrum disorder (ASD) is a behaviorally defined disorder that affects approximately 2% of children in the United States [1]

  • A computer-aided search of PUBMED, Google Scholar, CINAHL, EmBase, Scopus, and ERIC databases from inception through September 2021 was conducted to identify pertinent publications using the search terms “autism”, “autistic”, “Asperger”, “pervasive”, “ASD”, and “PDD” in all combinations with “folinic acid”, “leucovorin”, “folate”, “folic”, “methyl-folate”, “5MTHF”, “levofolinic”, “folinate”, and “formyltetrahydrofolate.” The references cited in identified publications were searched to locate additional studies

  • The pooled prevalence of cerebral folate deficiency (CFD) in ASD was 38% (11%, 71%) with a significant variation across studies due to heterogeneity driven by three studies with very high prevalence rates [34,36,68] and four studies with very low prevalence rates [37,45,70,71]

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Autism spectrum disorder (ASD) is a behaviorally defined disorder that affects approximately 2% of children in the United States [1]. Cerebral folate deficiency (CFD) has been reported in a number of studies in individuals with ASD and its treatment, d,l-leucovorin calcium ( known as folinic acid) has undergone investigation as a treatment for ASD [9]. In 1974, low levels of cerebrospinal fluid (CSF) folate were reported in patients with epilepsy that improved with tetrahydrofolate but not folic acid [15]. A study in 1976 reported 2 children with low CSF folate who developed intracranial calcifications [16]. In 1979, cerebral atrophy was reported in a 48-year-old woman with low serum and CSF folate [17]. In 1983, a case of a 23 year old woman with Kearns-Sayre syndrome and CNS deterioration was found to have decreased serum and CSF folate while taking phenytoin and improved with folic acid treatment [18]


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