Multiple Causes of Autism Spectrum Disorders

Multiple Causes of Autism Spectrum Disorders 
By Mark Sircus Ac., OMD Director International Medical Veritas Association
July 25, 2006

Autism and Birth

There are many things about pregnancy and birth that need to be factored into the autism equation. There is, for instance, information associating autistic disorders with the use of an artificial hormone (Pitocin) which is given to pregnant women to induce or speed up labor.  [i][1] Pitocin is a synthetic exogenous source of the natural hormone oxytocin which stimulates the gravid uterus to contract. It was developed as a drug by the Parke-Davis pharmaceutical company in 1953 and put into general use in 1955. It comes from the pituitary glands of cattle and includes acetic acid for pH adjustment and .5 percent chloretone as a preservative. Dr Eric Hollander of New York’s Mount Sinai School of Medicine, a physician who specializes in treating autistic kids, reported noticing that 60% of the autistic patients in his clinic had been exposed to this drug as a fetus.  [ii][2]Yet doctors like Ellen Grant find progesterones and oestrogens even more dangerous than Pitocin.
It is clear that the preponderance of available evidence 
suggests the importance of multiple biologic factors acting through 
one or more mechanisms to produce the autistic syndrome.
Dr. Donald J. Cohen & Fred Volkmar
Pitocin is not the only drug received by women whose labors are being induced or augmented. The use of Pitocin requires that the mother also be given IV fluids, have continuous electric fetal monitoring in place and remain sedentary in her hospital bed while connected to this equipment. Pitocin-induced uterine contractions and enforced maternal immobility makes labor more painful, so much so that under these circumstances most laboring women also receive narcotic pain relievers and/or epidural anesthesia.
Drugs used on pregnant women have never been tested to determine
 if they are safe for fetuses and neonates. Not a single one.
 No one has a clue about the long-term consequences.
California College of Midwives
Most labors today are induced at some point primarily because obstetricians are closing the birth canals of women by placing the expectant mothers in bed, keeping them on their backs and sacrum. “Being forced to immobilize her sacrum in a dorsal position, the laboring woman closes her birth canal up to 30% - a terrible mistake that is only aggravated when the OB chemically whips the uterus to contract violently with either Pitocin or Cytotec", writes Dr. Todd Gastaldo, a chiropractor who deals with the realities of the spine and the sacrum.
Most midwives understand the basic physics of birth where as obstetricians seem to want to defy the laws of gravity, deliberately making birth much more difficult than it has to be. Dr. Gastaldo warns us that pressures from a closed birth canal can distort the brain case causing brain bleeds and asphyxiation (prolonging delivery of the baby) of brain tissue. This compression leads to a series of complications forcing interventions - episiotomies, c-sections and drugging of the mother, which of course means the babies are drugged.
Just a two-minute delay in clamping a baby's umbilical cord 
can boost the child's iron reserves and prevent anemia for months.
University of California, Davis.[iii]
Most umbilical cords are clamped and cut[iv][4] before all the blood from the placenta is allowed back into the baby, meaning they start out with as much as a 40% decrease in blood volume.[v][5] Birth in itself is a shock to one degree or another. Babies need time to adjust, to light, to sound, to the simple act of breathing. But they are not given the time they need. As soon as they are born, antibiotic drops or ointment is put in their eyes and they are given a vitamin K shot. Trouble is the shot contains nasty chemicals like benzyl alcohol, phenol (carbolic acid), propylene glycol (antifreeze), acetic acid and hydrochloric acid.[vi][6]
Over 200 years ago Erasmus Darwin (Charles Darwin’s grandfather) was writing about early cord clamping and said, “Another thing very injurious to the child, is the tying and  cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child.”
An informal survey among midwives failed to identify babies born at home who have since been diagnosed with autistic disorders. It could be supposed that the people who gravitate to natural home births represent a sizable part of the small percentage of people who go against the lock step of society and do not vaccinate their children. Or the lack of aggressive medical interventions during birth can be seen as a key determinant in that it is absent when midwives are attending the birth. Dan Olmstead, doing investigative reporting for UPI, had a very difficult time finding any cases of autism in the Amish community. The Amish, with their belief in avoiding as much modern technology as possible, tend to mirror the experience of midwives meaning they gravitate to home births and away from childhood vaccinations.
The structural and functional integrity of the human brain is dependent on a continuous oxygen supply; lack of oxygen causes permanent brain damage. Midwives are much more likely to be gentle and surrendered to natural processes then hospital staffs and will let the baby adjust fully before clamping the umbilical cord. At birth, during the natural third stage of labor, placental oxygenation continues until pulmonary oxygenation is well established and until an adequate blood volume is achieved to circulate oxygen. Cutting this flow is an absolute and totally unnecessary threat to the child.
The current obstetrical practice of immediate and routine premature cord clamping jeopardizes the newborn's brain and other organs by interrupting placental oxygenation and placental transfusion, during the transition from "fetus" to "newborn".[vii][7] The newborn needs this blood to expand its lungs, so that they can take over the function of oxygenation from the placenta. Speaking about the rise of autism Dr. George Malcolm Morley and Eileen Nicole Simon PhD. say, “We propose that increased incidence of autism, infant anemia, childhood mental disorders and hypoxic ischemic brain damage, all originate at birth from immediate umbilical cord clamping. The influence of new environmental exposures, such as iatrogenic birth traumas, such as interruption of placental transfusion at birth, cannot be discounted.”[viii][8] 
When we add the Hep B vaccine a few hours later, with its aluminum hydroxide, thimerosal (in some countries) and modified genetic material one can only wonder about pediatricians and what they are thinking. In the September 14th issue of Neurology (2004; 63:838-42) a Harvard group published their findings confirming our worst fears about the recombinant hepatitis B vaccine and its role in increasing the chance of recipients contracting multiple sclerosis (MS).  Researchers from Harvard estimate that it increases the risk by over three times. This is highly significant to our multiple causes of autism model because, as suspected by Dr. Blaylock, this vaccine is creating problems in the brain’s immune system leading to serious auto-immune diseases. According to Blaylock, autism spectrum disorders are basically auto-immune disorders.
If the central nervous system becomes infected at a critical time, either before or after birth, Autism may result.
Prof. Uta Frith
Mercury exposure is a factor from conception onwards and starts early in pregnancy with the fully loaded mercury containing Rhogam shot for some women, the tetanus and flu shots - all of which still contain thimerosal. Then there is exposure to mother’s dental fillings leaking vaporous mercury, the mercury that mom consumes through eating too much fish, then the vaccines that are injected right from birth also containing mercury, besides the background mercury pollution in the air and water. The Rising Tide of Mercurya new book soon to be published by the International Medical Veritas Association, describes a nightmare that is increasing with each passing year. Simply put, we live in a mercury polluted world and that pollution gets worse each and every day. Clearly mercury is neurotoxic thus our children, who are the most vulnerable to toxic influences, will increasingly be put in harms way.
Most recently research is giving us one more reason to favor natural birth over Caesarean section that has implications for later development of neurological problems. A natural birth provides a baby with better protection against diseases and allergies than if it is born by Caesarean section, according to researchers at Glasgow University, who discovered that the gut of babies who had been delivered normally contained higher levels of "friendly" bacteria, such as bifidobacteria. These are particularly important, as they are the first bacteria to enter a child's digestive system and play a crucial role in developing the immune system.[ix][9]  
Professor Christine Edwards said, "If you are Caesarean delivered, you have to pick up bacteria from the environment around you - you are not getting exposure to your mother's bacteria. If you are born vaginally, you are getting bacteria from around that area, but if you are born by Caesarean you are in a very sterile environment when you are actually born." Edwards indicated that this first exposure to bacteria was significant for the child. "There are no bacteria in that baby at all. It's been living in an environment without any bacteria, and so the first ones that get in have a huge advantage over the competition. Your immune system is being taught by the bacteria starting to colonize your gut. Without bacteria in your gut, your immune system never develops properly." With many indications that autism and immune system weakness are related, we have every reason in the world to favor natural birth.

Autism and Nutrition

Many who love nutritional medicine feel that addressing diet and removing wheat and giving common nutrients like omega 3 oils and key minerals will go a long way to curing a child of neurological dysfunction.Research shows that children with autism and other developmental issues suffer from bowel disease and nutrition problems more frequently than their typical peers. When these children are treated nutritionally, many show dramatic improvement. This is especially true for minerals because our plants and soils are so nutrient depleted, even if we eat the healthiest foods, we are not getting all the minerals we need. All the weaknesses that predispose a child to neurodegeneration and those that prevent healing can be addressed powerfully with proper mineral supplementation.
Signs that diet intervention may benefit a child include: pallor, gray circles under the eyes, excessive drooling, eczema, diffuse dot rash on shoulders or limbs, white dots on nails, cracked or peeling nails, gray coated tongue, bright pink/red glossy tongue, red ears, cracks or rash at lips, anal itching, frequent illness, constant constipation and or unformed wet stools, reflux, hiccups, rigidity in food choices, poor picky appetite, colic, tantrums or poor sleep.
 Dr. Jill James of the University of Arkansas School of Medicine has documented a unique metabolic profile in 95 autistic children with regressive autism.[x][10]  Regressive autism is a form of the disease in which children develop normally for a certain period before losing previously acquired language or behaviors and being diagnosed with autism. The metabolic profile in the James study children manifests as a severe imbalance in the ratio of active to inactive glutathione in autistic children, compared to a group of healthy control children. Glutathione, a potent antioxidant, is the body's most important tool for detoxifying and excreting metals and its production in the body is dependent on good nutrition.
The James study shows that children with regressive autism have consistently elevated levels of oxidative stress as compared to normal healthy children. Individuals with reduced glutathione antioxidant capacity will be under chronic oxidative stress and will be more vulnerable to toxic compounds that act primarily through oxidative damage, including mercury
Yet it seems like the American Academy of Pediatrics (AAP) lives on a different planet. To them “Autism is not a specific disease, but rather a collection of disorders of brain development with a strong genetic basis, although its exact cause is not entirely known.” [xi][11] Yet most doctors know, "It is impossible to have a sudden epidemic of a genetic disease. The genetic factor or other predisposing weakening factor is there but it needed the environmental trigger to make it surface. That's why we think the genetic inability to excrete mercury e.g. Apo-E4 and/or a metallothionine abnormality underlies those that crash after being exposed to mercury injections," says Dr. Michael Godfrey.[xii][12] Dr. James and coworkers showed that there were abnormalities in several of the substances involved with the methionine cycle (also called the methylation cycle) and the transsulfuration pathway in children with autism. These are important in the synthesis of glutathione, which was found to be about 80% depleted in children with autism.
Magnesium deficiency measured in 95% of 116 Polish children with ADHD:
78% low hair, 59% low RBC's, 34% low serum.[xiii]
A case can easily be made that substitutes what allopathic medicine considers background genetic disposition for nutritional deficiencies. According to Dr. Ellen Grant, nearly all the autistic children tested at Biolab had zinc, copper, SODase and magnesium deficiencies. We know that mercury displaces essential elements like magnesium, zinc and copper from cells causing disruptions of enzyme systems in the process. So we can expect, when we correct nutritional deficiencies, that we will see a reversal in symptoms. So for instance a double-blind administration of 200 mg elemental magnesium per day to 25 children produced measurable decrease in hyperactivity over 6 months compared to control.[xiv][14]
Impaired antioxidant production provides a common rationale 
for many disparate features of autistic disorders.
Serious vitamin and mineral deficiencies weaken the immune system and lead to developmental problems independently of other factors. This is a crucial point that was made after the deaths from encephalopathy of two Israeli infants who were exclusively fed a soya formula made in Germany that lacked vitamin B1 (thiamin).[xv][15]  A recent documentary on these children show the most seriously disabled staring into space and barely able to move. While some babies being treated are improving, others seem to be irreversibly damaged with several of them feeling no pain and never able to cry. Complete nutrition is crucial for neurological development and function and any kind of nutritional deficiency will weaken children leaving them more vulnerable to diseases of all kinds.
Naturally some children would be better mercury eliminators than others, and some kids just can stand higher levels of toxicity without falling apart. Most of medicine and science is geared to examining toxic influences and not deficiency disorders. Deficiencies in basic minerals like magnesium and selenium can make all the difference between health and disease, between being able to withstand chemical attack and not. Constant low level mercury stress in the body will diminish selenium because of the high affinity between these two elements and this is a big problem because of diminished glutathione production when selenium is not available.
 One deficiency that is never thought of, especially in pediatrics unless a child is acutely ill is dehydration – water deficiency. Unintentional dehydration is more common than anyone acknowledges and is an easy condition to fall into for child or adult. Many of the soft drinks we give children actually dehydrate the body and much of the water we do drink is actually poisoned with chemicals either deliberately put there (fluoride, chloride, chloramines) or leached into the ground water from a myriad of pollution sources, and even neurotoxic lead is still present because it is still in pipe fixtures. It might come as a shock that something as simple and basic as water can be a cause of neurological disorders in children but just imagine the difference and the vast complications that ensue in the body when it is dehydrated; when it’s plum-like and juicy cells become transformed into prune-like and drying cells because of insufficient water.[xvi][i][16] Dehydrated cells don’t do anything as well as hydrated ones and that includes dealing with toxic insults.  
Water is the most basic of all nutrients.
It should be noted that no matter what a child’s genetic background and strength is, or what deficiency that is present in the body, there is a certain level of thimerosal or general mercury poisoning that will kill them; that will begin to destroy their nervous system leading to general autistic decline. The exact amount just happens to vary widely from child to child. Autism is not a genetic disease; there is no proof to indicate it is. It is only the handiest theory for pediatricians to explain what they do not want to understand.
Measles virus exhausts the immune system, leading to increased susceptibility 
to subsequent microbial infections. This scenario is more likely in the 
malnourished child, especially with vitamin A deficiency.[xvii]
                                                                        Dr. Russell Blaylock
Nutrition is a vast subject with a large impact for neurologically dysfunctional children. It also opens the door to detoxification and chelation protocols that can also be driven through nutritional principles and supplementation.

Where Physiology and Psychology Meet

The hours, days and months following birth are undoubtedly the most critical phases in the life of human beings. It is a sad reality of modern life that has infants routinely disturbed physiologically and psychologically by medical interventions administered from the first moments of life. Doctors have decade-by-decade intensified their interference with natural childhood development sequences without regard to serious deleterious outcomes or effects.
The recent explosion in autism does run parallel with the increases in injections,[xviii][18] but no one has been paying attention to the possible emotional collateral effects to what is being done to infants. Most physicians can hardly believe that emotions matter in health or disease at all or that they might contribute significantly to disorders like cancer and heart disease and even fewer would think that stabbing infants with poison would bother them. At least one medical scientist has tested hundreds of babies for subtle changes. Dr. Viera Scheibner recorded the breathing of babies with computerised Cotwatch Breathing Monitors saw that many of them changed their breathing patterns soon after vaccination. Within an hour stress level in breathing increased and was clearly visible on the computer printouts. Just because a doctor cannot see and perceive something to be there does not mean its not.
Emotions physiologically are chemicals raging through
 the blood stream, products of endocrine function.
In psychology there is a syndrome called Post-Traumatic Stress Disorder (PTSD), which has been studied thoroughly on biological and emotional levels. Daniel Golemen in his book Emotional Intelligence tells us, “Any traumatizing event can implant such trigger memories in the amygdale.” Dr. Dennis Charney, a psychiatrist and director of clinical neuroscience at the National Center at Yale University tells us that, “It does not matter if it was the incessant terror of combat, torture, or repeated abuse in childhood, or a one-time experience. All uncontrollable stress can have the same biological impact.” The operative word here is uncontrollable. The key psychological aspect of PTSD is helplessness, the feeling that you are being threatened or your life is in danger and there is absolutely nothing you can do to avoid it.[xix][19] Dr. Charney said, “Victims of devastating trauma may never be the same biologically.” And Dr. John Krystal, director of the Laboratory of Clinical Psychopharmacology, says, “It’s the feeling that your life is in danger and there is nothing you can do to escape it – that’s the moment the brain change begins.”
Over the last 30 years increasing evidence has been found
 for the existence of complex links between the immune system, 
the central nervous system and the endocrine system on
 the one hand, and psychological phenomena on the other.
                                                                                  Van Gent, et al.[xx]
Dr. Boyd Haley has already shown in his laboratory at the University of Kentucky how even relatively benign substances like Tylenol and endocrine hormones like testosterone increase mercury’s toxicity, which explains at least partially why more boys succumb to autism than girls. But perhaps part of the sex difference is from the effects of PTSD in the boys from the medical circumcisions they endure. Some people think that routine infant circumcision is the cruelest and most barbaric, sadistic, and senseless child abuse and torture ever invented. Some mothers feel that the trauma of circumcision interferes with breastfeeding, thus it also interferes during an important time of bonding between mother and child.
Allopathic medicine has a very difficult time relating to children 
as sensitive beings who have feelings that matter clinically.
Modern man tends to belittle the feelings and emotions of young children. Adults who have lost the ability to be vulnerable with their own inner feelings have little or no capacity to empathize with little boys who might be reacting in far stronger ways than anyone imagines to medical circumcision. Medical circumcision cannot be considered the same as the spiritual and religious rituals carried out with the utmost of care.  
Children without doubt find vaccination a traumatic experience though it seems as if most would get over it quickly. Today though they are given up to four shots at a time and this significantly amplifies the trauma. It is important to remember the key to Post Traumatic Stress Syndrome is helplessness. It should not be too difficult to see the possibility that bringing in a child for multiple dangerous injections could provoke a change in internal brain chemistry, when they are dragged against their will, into a danger that could kill them. Or as the VAERS system clearly shows, all too easily send them to the hospital because of convulsions and exceptionally high fever.
It is just a fact that for some children vaccines are lethal injections and for others it brings on severe enough consequences to hospitalize them. Any psychologist involved with PTSD would probably agree that this could qualify for an uncontrollable stress event that can result in some kind of biological impact. 
Many doctors would laugh thinking how could children know, think or feel that they are in danger when the doctors themselves think they are doing no harm but only good in administering the vaccines. But veterinarians are well aware of the capacity of animals to intuit danger. Young children have this same basic capacity to sense danger and no doubt their crying and screaming as they are dragged into receive their needles is a good indication of this.
“When I brought my son in for his Hep B inoculation, he went screaming and flailing like a banshee Indian, and it took 5 people just to hold him down, totally against his will.  It took me a long time to regain his trust,” wrote Claudia French RN. Maureen Fontaine, remembering back to age two said,  “I lost trust for my mother on that day she brought me in for my shots and I never ever did completely recover that trust with her.”[xxi][21]
Babies scream without end when they are violated and hurt
 in a way that challenges their capacity to endure.
 It does not take a great stretch of the imagination to see that we might have a very special case when PTSD psychological and biological changes come together with heavy toxic loading from vaccines combining to form a special matrix of changes in both immune and brain chemistry. Any in-depth theory of autism spectrum disorders has to include some analysis of why some kids fall in neurological dysfunction and others not. Both emotional and nutritional factors are important in differentiating one child from another. Nutritional deficiencies also have a great bearing on the emotional life of children and their strength to withstand both emotional and chemical shocks. 


We are only now waking up to the full dimension of the nightmare and to a form of medical insanity that has been increasing decade by decade. Newborns and young children are being subjected to increasingly aggressive interventions and they are not standing up well to the assault. The conclusion of course is devastating. Autism is primarily an iatrogenic disease. It is caused mostly by obstetricians, pediatricians, their nurses who inject toxic chemicals into the babies, and even by dentists who expose mothers to mercury through their dental fillings. But coming up fast as a primary cause are environmental hazards especially mercury, which we find increasingly in our air, water and food.
The causes of autism are known, it just so happens that many people do not want to face the truth of the causes and this is in and of itself a further crime of the medical establishment, especially the branch of pediatrics. Denial only continues the horror and the suffering by blocking appropriate treatments and removal of the insulting causes. The medical establishment has completely abandoned its responsibilities of protecting the young from harm and is not even warning parents about the environmental hazards from mercury. Health and governmental organizations should be the first ones fighting for the conditions that will insure the health of our children but instead we find them in bed with the pharmaceutical companies and other industries that are just exposing them to more and more mercury and other poisons. 
International Medical Veritas Association 
Copyright 2006 All rights reserved.
[1] Newsweek Magazine, July 31, 2000 and  Care in Normal Birth: A Practical Guide—W.H.O’s “Safe Motherhood” series
[2] Silverman, Linda. The Institute for the Study of Advanced Development We’ve found a surprising number of gifted children with sensory-motor delays at the Gifted Development Center. Many of these children were the product of very long labors, emergency C-sections, a cord wrapped around part of the body, or the need of oxygen at birth. Recently, another potential culprit has emerged. One of our staff psychologists, Helen McVicar, noticed a relationship between long hours of pitocin and sensory integration problems in children. In her research, Helen learned that pitocin was developed to be used for up to three or four hours to induce labor, but it is commonly used for longer periods.
[4] Mid Wife Info. "Immediate clamping of the umbilical cord can reduce the red blood cells an infant receives at birth by more than 50%, resulting in potential short-term and long-term neonatal problems." So concluded Judith Mercer, CNM and colleagues in a study reported in the fall of 2001 in the Journal of Midwifery and Women's Health (Mercer, 2001). "Early clamping of the umbilical cord at birth, a practice developed without adequate evidence, causes neonatal blood volume to vary 25% to 40%. Such a massive change occurs at no other time in one's life without serious consequences, even death. Early cord clamping may impede a successful transition and contribute to hypovolemic and hypoxic damage in vulnerable newborns" (Mercer, 2002).
[5] Morley, George M. Immediate clamping of the umbilical cord (ICC) at birth, a possible connection to Autism? ICC is routinely applied during premature, operative and "at risk" births, and increasingly during "normal" births following the recommendation (4) that a segment of the cord should be retrieved immediately after delivery for medico-legal purposes. The immediate effect of ICC is to deprive the neonate of placental respiration and transfusion resulting in complete asphyxia until the lungs function, and 30%-50% loss of the neonate's natural blood volume; the combined hypoxia and hypovolemia / ischemia is then conducive of hypoxic ischemic brain injury. The neonate that receives a full placental transfusion has enough iron to prevent anemia during the first year of life(5), but blood loss in a neonate subjected to ICC becomes evident in infancy as anemia.(5) In grade school children, anemia correlates with all types of autistic disorder (6) and the degree of anemia correlates with the degree of mental deficiency; (7) correcting the anemia does not correct the defect. Kinmond et al. (8) showed that delayed cord clamping combined with gravity assisted placental transfusion prevented anemia (the need for blood transfusion) in preemies. Hack et al. (9) found a high incidence of poor achievement in low birth weight babies. The correlation between autism and birth complications is supported by aother sudies. Hultman (10) reports a great increase in the risk of autism in cesarean deliveries, deliveries with fetal distress and five minute Apgar scores below seven. These obstetrical situations correlate with ICC.  
[6] Israels LG. Observations on vitamin K deficiency in the fetus and newborn: has nature made a mistake? Department of Medicine, University of Manitoba, Manitoba Institute of Cell Biology, Winnipeg, Canada. Semin Thromb Hemost 1995;21(4):357-63
[7] Morley, George M. Simon. Nicole. Brainstem Lesions in Autism: Birth Asphyxia and Ischemia as Causative Factors. Nov 1. 2002
[8] Morley, George M. Simon. Nicole. Brainstem Lesions in Autism: Birth Asphyxia and Ischemia as Causative Factors. Nov 1. 2002
[11] news release on a policy statement published in the May issue ofPediatrics, the peer-reviewed scientific journal of the American Academy of Pediatrics (AAP).
[12] Personal Email – Dr. Michael Godfrey – 6/5/2004
[13] Magnesium Research 10(2): 143-148 1997
[14] Magnesium Research 10(2): 149-156 1997
[15] BMJ 2003;327:1128
[16] F. Batmanghelidj M.D. Water Cures: Drugs Kill. How Water Cured Incurable Diseases.
[17] Blaylock, Russell. The Central Role of Excitotoxicity in Autism Spectrum Disorders . Jana – Volume 6, No 1, 2003
[18] Incao, Philip -Hepatitis B Vaccination Testimony in Ohio - March 1, 1999
[19] Dr. Spencer Eth, a child psychiatrist, specialized in PTSD, describes the core of this syndrome as “the intrusive memory of a central violent action: a final blow from a fist, the plunge of a knife, the blast of a shotgun. The memories of intense perceptual experiences – the sight, sound, and smell of gunfire, the screams or sudden silence of the victim; the splash of blood; the police sirens.”
[20] Van Gent, et al. Autism and the Immune System, Journal of Child Psychology and Psychiatry, vol. 38 no. 3, March 1997, pp. 337-349
[21] Personal Emails September 2004