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Figure.
Multidimensional Scaling Analyses of Nuclear DNA Single-Nucleotide Polymorphisms From the Autism Genetic Resource Exchange Data Set
Multidimensional Scaling Analyses of Nuclear DNA Single-Nucleotide Polymorphisms From the Autism Genetic Resource Exchange Data Set

Each point represents a single individual plotted against the first 3 dimensions from the multidimensional scaling analysis. Each haplogroup is depicted as a different color. PC indicates principle component.

Table 1.  
Distribution of mtDNA Haplogroups Across the nDNA MDS Clusters
Distribution of mtDNA Haplogroups Across the nDNA MDS Clusters
Table 2.  
Generalized Linear Modeling Analysis Results With GEE Solution for the AGRE Family Data Seta
Generalized Linear Modeling Analysis Results With GEE Solution for the AGRE Family Data Seta
Table 3.  
Generalized Linear Modeling Analysis Results With GEE Solution for the AGRE Family Data Set Using Samples from MDS Cluster 1a
Generalized Linear Modeling Analysis Results With GEE Solution for the AGRE Family Data Set Using Samples from MDS Cluster 1a
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Original Investigation
November 2017

Association Between Mitochondrial DNA Haplogroup Variation and Autism Spectrum Disorders

Author Affiliations
  • 1Center for Mitochondrial and Epigenomic Medicine, Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
  • 2Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
  • 3Center for Systems Biomedicine, Division of Digestive Diseases, School of Medicine, University of California, Los Angeles
  • 4Institute of Memory Impairments and Neurological Disorders, Department of Neurobiology and Behavior, University of California, Irvine
  • 5Center for Applied Genomics, Department of Pediatrics, Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
  • 6Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia
JAMA Psychiatry. 2017;74(11):1161-1168. doi:10.1001/jamapsychiatry.2017.2604
Key Points

Question  Is there an association between mitochondrial DNA haplogroup-linked functional variants and risk of autism spectrum disorders (ASD)?

Findings  In this study, based on 1624 patients with ASD and 2417 healthy parents and siblings from 933 Autism Genetic Resource Exchange families, individuals with European haplogroups I, J, K, O-X, T, and U and Asian and Native American haplogroups A and M are at significantly increased risk of ASD compared with the most common European haplogroup HHV.

Meaning  Functional mitochondrial DNA variants associated with haplogroups may contribute to the risk for ASD, supporting the role of mitochondrial dysfunction in ASD.

Abstract

Importance  Autism spectrum disorders (ASD) are characterized by impairments in social interaction, communication, and repetitive or restrictive behavior. Although multiple physiologic and biochemical studies have reported defects in mitochondrial oxidative phosphorylation in patients with ASD, the role of mitochondrial DNA (mtDNA) variation has remained relatively unexplored.

Objective  To assess what impact mitochondrial lineages encompassing ancient mtDNA functional polymorphisms, termed haplogroups, have on ASD risk.

Design, Setting, and Participants  In this cohort study, individuals with autism and their families were studied using the Autism Genetic Resource Exchange cohort genome-wide association studies data previously generated at the Children’s Hospital of Philadelphia. From October 2010 to January 2017, we analyzed the data and used the mtDNA single-nucleotide polymorphisms interrogated by the Illumina HumanHap 550 chip to determine the mtDNA haplogroups of the individuals. Taking into account the familial structure of the Autism Genetic Resource Exchange data, we then determined whether the mtDNA haplogroups correlate with ASD risk.

Main Outcomes and Measures  Odds ratios of mitochondrial haplogroup as predictors of ASD risk.

Results  Of 1624 patients with autism included in this study, 1299 were boys (80%) and 325 were girls (20%). Families in the Autism Genetic Resource Exchange collection (933 families, encompassing 4041 individuals: 1624 patients with ASD and 2417 healthy parents and siblings) had been previously recruited in the United States with no restrictions on age, sex, race/ethnicity, or socioeconomic status. Relative to the most common European haplogroup HHV, European haplogroups I, J, K, O-X, T, and U were associated with increased risk of ASD, as were Asian and Native American haplogroups A and M, with odds ratios ranging from 1.55 (95% CI, 1.16-2.06) to 2.18 (95% CI, 1.59-3) (adjusted P < .04). Hence, mtDNA haplogroup variation is an important risk factor for ASD.

Conclusions and Relevance  Because haplogroups I, J, K, O-X, T, and U encompass 55% of the European population, mtDNA lineages must make a significant contribution to overall ASD risk.

Introduction

Autism spectrum disorders (ASD) are characterized by impairments in social interaction, communication, and repetitive or restrictive behaviors but can also present with a broad range of associated symptoms,1,2 including general weakness, gastrointestinal dysfunction, and epilepsy. The incidence of ASD is rising in the United States and as of 2010, the prevalence of ASD among 8-year-old children was 1 in 42 in boys and 1 in 189 in girls (male to female ratio is 4:1).3 Analysis of nuclear DNA (nDNA) genetic variation has revealed large numbers of associated heterozygous copy number variants (CNVs)4,5 and loss-of-function mutations,6-8 most of which account for only a few cases,1,6,7,9,10 suggesting a polygenic origin of ASD.11 Metabolic profiles of patients with ASD are consistent with mild mitochondrial defects,12,13 with oxidative phosphorylation (OXPHOS) defects having been reported in ASD lymphocytes,14 muscle,15 and brain.16,17 Autism spectrum disorder CNVs frequently delete nDNA genes that could perturb mitochondrial function,18 and ASD loss-of-function gene mutations can affect mitochondrially related functions such as variants in the Wnt β-catenin signaling pathway and associated chromodomain helicase DNA-binding protein 8 genes,6,19 as well as calcium regulation and fatty acid oxidation genes.7 Although arising heteroplasmic mitochondrial DNA (mtDNA) base substitution mutations have been observed in patients with ASD,20-22 the role of ancient mtDNA polymorphisms has not been rigorously evaluated, to our knowledge.

The mitochondrial genome consists of 1000 to 2000 nDNA genes plus hundreds to thousands of copies of the mtDNA per cell. The mtDNA codes for 13 of the most important polypeptides of OXPHOS plus the ribosomal RNA and transfer RNA for their translation in the mitochondrion. Hence, mtDNA variants directly affect cellular energy metabolism.23

There are 3 clinically relevant types of mtDNA variation: ancient adaptive haplogroup-associated polymorphisms that are homoplasmic (single pure mtDNA allele), recent deleterious mutations that have arisen in the female germline within the past 10 generations and can be either homoplasmic or heteroplasmic (mixture of 2 mtDNA alleles), and developmental arising somatic mutations that are invariably heteroplasmic.23 Ancient haplogroup-associated mtDNA variants have accumulated along radiating maternal lineages throughout human history, initially in Africa giving rise to macrohaplogroup L. About 65 000 years ago, women carrying 2 mtDNAs (M and N) left Africa for Eurasia, giving rise to macrohaplogroups M and N. Macrohaplogroup N settled in Europe and generated haplogroups HHV, J, T, U, K (Uk), I, W, and R. Macrohaplogroups M and N settled in Asia and generated 49% and 51% of the Asian mtDNAs, respectively. Asian macrohaplogroup M gave rise to multiple additional M sublineages (M1-M80), which include haplogroups C, D, G, and Z, while Asian macrohaplogroup N gave rise to Asian lineages A, B, F, O, and others. Eurasian haplogroups A, B, C, D, and X mtDNAs then came to the Americas.24 Because the mtDNA does not recombine, all single-nucleotide variants (SNVs) of an mtDNA lineage are in total disequilibrium and function as a unit. Hence, defining the haplogroup also defines its linked functional variants.

The various mtDNA haplogroup lineages arose and radiated within regional indigenous populations and are functionally different. Therefore, their proliferation within specific environments was due to adaptive selection. Although these variants are adapted to 1 regional environment, changes in the environment, such as migration, changes in diet, or new infection agents, can be maladaptive for a particular mtDNA lineage resulting in clinical phenotypes.24

Given the genetic complexity of ASD and the association of autism with mitochondrial bioenergetic defects, mtDNA variation should contribute to ASD risk. Because our objective was to determine whether inherited mtDNA variation contributes to ASD risk, we analyzed the Autism Genetic Resource Exchange (AGRE) family cohort.25 This cohort is particularly appropriate for detecting inherited subclinical risk factors, such as mtDNA variation, because it has been found that in 21 of 30 AGRE multiplex families affected by known risk CNVs (70%), a de novo or inherited event was not shared by all affected children.5

Methods
Participants

The mtDNA SNVs were determined by the Children’s Hospital of Philadelphia Center for Applied Genomics using the Illumina HumanHap 550 (Illumina Inc) array during the genome-wide association study analysis of AGRE families.26,27 Individuals were recruited in the United States with no restrictions on age, sex, race/ethnicity, or socioeconomic status, and they completed informed consent through the genome-wide association studies separately. Acquisition and analysis of the data for this study were approved by the Children’s Hospital of Philadelphia institutional review board and began in October 2010, and analysis ended in January 2017. The AGRE database was downloaded as PLINK files along with the family relationships and phenotypes. Among the samples in the PLINK files, 27 individuals (7 families) were missing from the downloaded AGRE phenotype file and were excluded from further analysis. The resulting genotyped AGRE data set included 4300 individuals, comprising 934 families with 1 to 12 members. Based on the Autism Diagnosis Interview score, 1624 individuals were diagnosed as having autism, 1 as having ASD, 156 as being on a broad spectrum, 74 as not quite having autism, 1 as having paranoia personality disorder–not otherwise specified, and 27 as not meeting the criteria for autism. The last 259 individuals without autism were excluded from analysis. The final total sample encompassed 933 families, including 1624 patients with ASD and 2417 healthy parents and siblings (N = 4041). Most of the AGRE samples in this study had mtDNA lineages of European origin, with some Asian, Native American, and African contributions.

Data Acquisition

The mtDNA variants on the Illumina HumanHap 550 array were designed based on the African Yoruban mtDNA sequence (GenBank AF347015). Therefore, we converted the variant positions to the corresponding positions in the revised Cambridge Reference Sequence (GenBank NC012920).28 The corresponding SNVs are listed in eTable 1 in the Supplement. The 163 mtDNA SNVs interrogated by the Illumina HumanHap 550 single-nucleotide polymorphisms chip,26,27 which passed stringent quality control measures, were used in this analysis. Using the aggregate SNVs for each individual, the mtDNA haplogroup of each individual was deduced by identifying the best match of those variants to the variants in the mtDNAs encompassed within the global phylogeny of complete mtDNA sequences using HaploGrep.29

To determine the accuracy and specificity of mtDNA haplogroup interpolation using the 163 mtDNA SNVs, we obtained 30 589 mtDNA GenBank sequences and used HaploGrep29 to infer haplogroups at the 1-letter haplogroup level from the entire mtDNA sequence. We then extracted SNVs interrogated by the Illumina HumanHap 550 array and again used HaploGrep to infer haplogroups from the 163 SNVs (eTable 2 in the Supplement). Of the 28 haplogroups tested, haplogroups A, C, D, I, J, K, L, and M (haplogroups M1-M80, except M7 and M8, and G and D); N (all N haplogroups, except N1, N2, and N9, and A, X, and R); and T, U, V, and W were inferred correctly in essentially all cases.30 Minor ambiguities were found when deducing haplogroups B, E, F, G, H, HV, O, P, Q, and R (R1-R32, except R9, and P); R0; and X. The sensitivity ranged from 0.17 to 1.00 (mean, 0.89; median, 1.00), and specificity ranged from 0.99 to 1.0. To resolve misclassifications, we represented the haplogroup information as a graph, with each node being a haplogroup and an edge between 2 nodes if there was an ambiguity between the 2 haplogroups. We then computed connected components using the R software package with igraph package, version 1.0.0 (http://igraph.org) to cluster the ambiguous haplogroups into 3 computational macrohaplogroups, which we termed N+ (N [all N haplogroups, except N1, N2, and N9, and A, X, and R] and S), HHV+ (B, F, H, HV, P, and R [R1-R32, except R9, and P]; R0; and V), and O-X (O, X). Except for haplogroup C, all of the subhaplogroups in macrohaplogroup M were ambiguous and therefore clustered. Given that there was a relatively small number of individuals in both the M macrohaplogroup and C haplogroup in the AGRE population and that C falls under the M8 subtree, we treated macrohaplogroup M in totality including C. Although the N1 haplogroup includes haplogroup I, there were only 26 individuals who were classified as N1 but not part of I, so they were omitted from analysis. For completeness, we repeated our analyses with different combinations of classifications of individuals based on the phylogenetic tree30 including both collapsing and separating haplogroups C and macrohaplogroup M, I and N1, J and T, and U and K, and the corresponding results remained consistent.

Computational haplogroup HHV+ encompasses 44% of the AGRE mtDNAs consistent with European population studies that have revealed that haplogroup HHV encompasses between 40% and 42% of European mtDNAs.31 Although H, HV, R, and R0 are all European, closely related, and thus functionally similar, haplogroup B is Asian and Native American, and F is Southeast Asian. Because of its geographic origin, F is unlikely to be prevalent in the AGRE data set. Hence, in the HHV+ computational macrohaplogroup, only B is not closely related to European HHV. Assuming that in the AGRE sample, most North American B mtDNAs are Native American in origin, we can estimate the proportion of HHV+ that could be B. Among Native American individuals, N (A + B) = 59% and M (C + D) = 41%. Within N, A = 56% and B = 43%.32 Hence, B = 77% of A. In the AGRE sample, there are 128 individuals in haplogroup A. Therefore, the number of individuals in haplogroup B is approximately 98 or at most 6% of HHV+.32 Asian haplogroup O is also rare in North America, so O-X is essentially X. Last, the AGRE sample encompasses too few African haplogroup L mtDNAs to justify further subdivision. Hence, in our analysis, we aggregated all Ls under the single macrohaplogroup L.23

Statistical Analysis

Because the sampling strategy for the AGRE sample set is not random, the degree of association between nDNA genetic variants and mtDNA variants could be a confounding factor. This prospect could be particularly problematic if there were high ethnic heterogeneity in the sample and strong assortative mating within the ethnic groups. To investigate the potential importance of nDNA population substructure, we analyzed the genome-wide association study nDNA SNV variation26,27 using multidimensional scaling (MDS) analyses performed using PLINK, version 2.0 (http://www.cog-genomics.org/plink/2.0/) and restricting the analysis to 5 clusters (Figure).

To determine whether the nDNA MDS clusters correlated with the mtDNA haplogroups, we compared the distribution of mtDNA haplogroups associated with each MDS cluster. This analysis revealed that most mtDNA haplogroups were distributed across different clusters (Figure and Table 1) and that the mtDNA haplogroups did not significantly correlate with the clusters (weighted Cohen κ < 0.003). Hence, the haplogroups and MDS clusters represented different subgroups such that mtDNA haplogroup associations are unlikely to be the result of the spurious association between population-specific nDNA variants that are inherited along with mtDNA haplogroups due to assortative mating. Comparing the nDNA clusters with ASD revealed that only the first cluster was a significant predictor of ASD risk, consistent with nDNA genetic variation contributing to ASD risk, as expected.

Having defined the integrity of the haplogroup imputations and determined the potential effects of nDNA variation, we then analyzed the relationship between mtDNA haplogroup variation and ASD using MDS clusters 1-5 (C1-5) as a covariate along with haplogroup and sex. Our study comprises families of related individuals, and because the risk of autism increases if 1 family member has autism, family members cannot be analyzed as statistically independent. To take into account the family structure of the AGRE data set, we applied generalized linear modeling and adopted the generalized estimating equations approach to determine the significance of ASD-haplogroup associations (SAS PROC GENMOD; SAS Institute Inc).33,34 This generalized estimating equations approach involves computing the average response over the population and uses weighted combinations of observations for correlated data.35 When the number of classes is large as is the case here, the generalized estimating equations method provides a robust solution to modeling family-based, correlated samples.36 The data were modeled using a binary response variable of whether the individual was diagnosed as having ASD and a logistic link function and binomial distribution (SAS parameters: /DIST = binomial LINK = LOGIT). The exchangeable correlation matrix was used with the repeated individuals being family members to capture the family correlation structure.37,38 The stepdown Bonferroni and Benjamini-Hochberg false discovery rate correction procedures were used to adjust for multiple testing.39

Results

Using the AGRE data set consisting of 933 families, including 1624 individuals with known ASD status and 2417 healthy parents and siblings (N = 4041), we determined whether there was a difference between haplogroups, sex, and MDS C1-5. We chose as a reference the computational macrohaplogroup HHV+, which is composed primarily of European haplogroup HHV. Haplogroup HHV is the most prevalent European haplogroup and encompasses the revised Cambridge Reference Sequence for the mtDNA.28

The parameters of a logistic model for sex and mitochondrial haplogroup were determined (Table 2). As expected, sex was a significant predictor of increased risk of ASD in boys vs girls (odds ratio [OR], 3.93; 95% CI, 3.30-4.67; stepdown Bonferroni P < .001) (Table 2). This OR is similar to the reported ratio of affected boys vs girls, providing validation for the model.

We then analyzed the haplogroups relative to HHV+ and found that European haplogroups I, J, K, T, and U were all at significantly higher risk for ASD (range: OR, 1.76; 95% CI, 1.31-2.36 and OR, 2.18; 95% CI, 1.59-3) at the 0.05 Benjamini-Hochberg adjusted significance level. Computational macrohaplogroup O-X was also at increased ASD risk (OR, 2.00; 95% CI, 1.23-3.25), as were Asian and Native American haplogroup A and macrohaplogroup M (OR, 1.83; 95% CI, 1.32-2.53 and OR, 1.55; 95% CI, 1.16-2.06, respectively) (Table 2).

Because MDS C1 proved to be a strong covariate but with very high variance, we attempted to control for its effects by confining our mtDNA haplogroup analysis to only those samples encompassed by MDS C1. Multidimensional scaling C1 encompasses 3401 of 4041 individuals in the AGRE data set (84.2%), which includes 3153 of 3380 European mtDNAs (HHV+, I, J, K, T, U, and W) (93.3%) but 69 of 196 African L mtDNAs (35.2%) (Table 1). Hence, MDS C1 encompasses predominantly individuals of European ancestry.

The generalized estimating equations analysis of MDS C1 individuals revealed that European haplogroups I, J, K, T, and U had significantly higher risk of ASD than HHV+ (range: OR, 1.87; 95% CI, 1.34-2.61 to OR, 2.27; 95% CI, 1.35-3.81). Only European haplogroup W was not associated with increased ASD risk (Table 3). The Asian and Native American mtDNA haplogroups A and M were also at increased ASD risk (OR, 2.95; 95% CI, 1.92-4.52 and OR, 3.14; 95% CI, 2.08-4.75, respectively) as were computational O-X haplogroups and macrohaplogroups N+ (OR, 2.01; 95% CI, 1.21-3.34 and OR, 4.52; 95% CI, 1.96-10.41, respectively) (Table 3). Therefore, even if we focus only on MDS C1, the association between ASD risk and mitochondrial haplogroups remains intact and is in fact stronger.

Although there is interplay between the nDNA and mtDNA in determining ASD susceptibility, our data demonstrate that mtDNA haplogroup variation significantly imparts differential risk for ASD. This result supports a mitochondrial component to the causes of ASD.

Discussion

Our linkage of mtDNA haplogroups to ASD supports the hypothesis that mitochondrial functional variation is important in the causes of ASD. A familial predisposition to ASD based on mtDNA background haplogroup may provide 1 explanation for why high-impact CNVs do not consistently correlate with the development of ASD among siblings.5 Because the mitochondrial genome encompasses both nDNA and mtDNA mitochondrial genes, in the face of predisposing mtDNA haplogroups, additional nDNA and mtDNA variants or environmental insults could lower mitochondrial function below the minimal bioenergetic threshold for normal brain function resulting in clinical manifestations and accounting for the polygenic nature of ASD.11

If mtDNA variation is an important component of ASD risk, then we would expect all 3 classes of clinically relevant mtDNA variants to correlate with ASD: ancient homoplasmic adaptive polymorphisms, recent homoplasmic or heteroplasmic deleterious mutations, and de novo heteroplasmic somatic mutations. In our study, we have found that homoplasmic functional mtDNA variants linked within mtDNA haplogroups24 contribute to ASD risk. Concurrent with our study, an analysis22 was performed of heteroplasmic mtDNA variation found in off-target mtDNA sequence data from 903 Simons Foundation Simplex mother-proband-sibling trios. This study revealed that ASD probands were more likely to harbor deleterious heteroplasmic mtDNA mutations than their unaffected siblings. The putative deleterious mutations were primarily present in 5% to 20% of the mtDNAs as heteroplasmic mutations. Although at least 1 high-confidence heteroplasmic mutation was found at an equal frequency in probands (21.2%) and siblings without autism (20.2%), the incidence of heteroplasmic mutations at nonpolymorphic sites was 53% higher in autistic probands compared with siblings. Moreover, probands harbored 52% more nonsynonymous mutations and 118% more predicted pathogenic mutations than siblings. Thus, nonsynonymous mutations were enriched approximately 1.5-fold, and potentially pathogenic mutations were enriched approximately 2.2-fold in probands. Hence, probands carrying nonsynonymous private heteroplasmic mutations had an ASD OR of 2.55 (95% CI, 1.26-5.51).22 Because these heteroplasmic mutations encompassed both mutations transmitted from heteroplasmic mothers as well as de novo mutations found only in the proband, these heteroplasmic mutations must encompass newly arising pathogenic germline mutations as well as deleterious somatic mutations arising during development.

Haplogroups I, J, K, O-X, T, and U represent approximately 55% of European mtDNAs. When combined with the more deleterious heteroplasmic mutations found in one-fifth of the newborns with ASD, mtDNA variation would appear to account for a significant proportion of ASD risk.22

The unique genetics of the mitochondrion can now account for many of the puzzling features of ASD genetics. The male bias of ASD is consistent with the male bias observed for the onset of blindness in patients with Leber hereditary optic neuropathy (male to female ratio is approximately 4:1), which is caused by mild homoplasmic mtDNA mutations.40 The female protection from blindness has been attributed to the presence of the estrogen receptor in the mitochondrion such that estradiol increases mitochondrion antioxidant defenses.41,42

Mitochondrial OXPHOS is also acutely sensitive to inhibition by agricultural and industrial toxins that are increasing in the environment and food supply.43 The added inhibition of OXPHOS by toxins could increase the penetrance of the milder haplogroup-associated variants, explaining the rising incidence of ASD.

The chance acquisition of a more deleterious de novo mtDNA mutation in 1 of the 20% of siblings who acquire a heteroplasmic mtDNA mutation or the chance inheritance of an nDNA CNV or loss-of-function mutation that partially impairs OXPHOS could all augment the haplogroup-based predisposition to ASD. This chance acquisition of additional mtDNA or nDNA mitochondrial variants or environmental insults could explain why in a maternal lineage with an ASD predisposing haplogroup, 1 sibling drops below the minimal bioenergetic threshold and manifests ASD while other siblings do not, giving rise to a bioenergetic polygenic cause.11

Finally, the neurobehavioral aspect of ASD can be related to the mitochondrial dysfunction through our mouse studies.44 We have found that mild mitochondrial OXPHOS inhibition perturbs the migration of the γ-aminobutyric acidergic inhibitory neurons during neuronal development without perturbing the migration of the excitatory glutamatergic neurons. This would cause reduced neuronal inhibition creating hyperexcitation that could account for the hyperexcitability and perseverative behaviors associated with ASD.44

Limitations

Because the mtDNA haplogroups in the present study were deduced from genome-wide association study single-nucleotide polymorphisms data, it was not possible to analyze the same samples for recent deleterious and somatic mtDNA mutations. This type of analysis will become possible when whole mtDNA sequence data become available.

Conclusions

We have shown that mitochondrial haplogroups, with their associated functional variants, contribute a significant proportion of ASD risk, thus confirming that mitochondrial dysfunction is a significant factor in the cause of ASD. The interaction between the ancient haplogroup functional variants, recent heteroplasmic mtDNA mutations, mutation or deletion of 1 or more nDNA genes, and environmental insults that modulate bioenergetics may all combine to explain many of the unusual features of ASD genetics.

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Article Information

Corresponding Author: Douglas C. Wallace, PhD, Center for Mitochondrial and Epigenomic Medicine, Children's Hospital of Philadelphia, Department of Pathology and Laboratory Medicine, University of Pennsylvania, 3501 Civic Center Blvd, Colket Translational Research Bldg, Room 6060, Philadelphia, PA 19104 (wallaced1@email.chop.edu).

Accepted for Publication: July 6, 2017.

Correction: This article was corrected on October 4, 2017, to fix a missing degree in the author byline.

Published Online: August 23, 2017. doi:10.1001/jamapsychiatry.2017.2604

Author Contributions: Drs Singh and Wallace had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Chalkia and Singh served as co–first authors and contributed equally to the work.

Study concept and design: Chalkia, Singh, Derbeneva, Wallace.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Chalkia, Singh, Wallace.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chalkia, Singh, Leipzig, Lakatos, Wallace.

Obtained funding: Wallace.

Administrative, technical, or material support: Chalkia, Lvova, Derbeneva, Hadley, Wallace.

Study supervision: Hakonarson, Wallace.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grants MH108592, NS021328, and NS070298 from the National Institutes of Health and grant 205844 from the Simons Foundation (Dr Wallace).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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