Autism spectrum disorder: advances in diagnosis and evaluation

I thank the Commissioning Editor and the authors for a thoughtful and thought provoking order. ( Though as yet, from England, only Mr Stone and I have commented.

1, The authors refer to African Americans. At first glance you might assume that the term embraces ALL Americans who are descended from Africans or are migrants from Africa. This assumption misses the biological fact that, say a Kikuyo is as different from an Ibo as chalk is from cheese. You would not lump together the Norse and the Catalans.

2. The “African Americans are not homogeneous culturally either.

3. First Nations. Sioux of Alberta ( even though with some mixture with later arrivals, still are different from the Nova Scotians.

4. Homing in on the English scene, as Mr John Stone has repeatedly pointed out, the government is ignoring the rising numbers, thus ignoring the burden on the social services and on educational facilities, AS WELL AS on mental health services. Is it not obvious then, that the families of these children, adolescents and adults are shattered? I would like to know how Alberta is coping.

5. Aetiological factors.
a) One rapid response from the USA, suggests that certain animal fractions may have a protective effect. Would our MRC care to explore?
b) Another rapid response from the USA suggests that autoimmune antibodies may be responsible. This too ought to be explored by the English immnologists. And if it is the case, what are precipitating factors? Are we, somehow, distorting or overwhelming some immunological processess?
Would our neurologists and immunologists be kind enough o help?
Has the Dept of Health any views? Has its agent - NHS ENGLAND any views?

As I recorded in my letter below [1], I currently await some response from the Department of Health and Social Care about the rise in autism. When I was first in touch with them based on my experiences in Haringey in 2000 they sent me by way of reassurance a paper by Eric Fombonne, 'The epidemiology of autism: a review' (1999) [2], so it is is exceedingly interesting to compare the picture then with current data:

"Across surveys, the median prevalence estimate was 5.2/10000. Half the surveys had 95% confidence intervals consistent with population estimates of 5.4-5.5/10000. Prevalence rates significantly increased with publication year, reflecting changes in case definition and improved recognition; the median rate was 7.2/10 000 for 11 surveys conducted since 1989...There was no evidence for a secular increase in the incidence of autism. In eight surveys, rates for other forms of pervasive developmental disorders were two to three times higher than the rate for autism...Based on recent surveys, a minimum estimate of 18.7/10000 for all forms of pervasive developmental disorders was derived, which outlines the needs in special services for a large group of children."

It is interesting to notice that Fombonne's figure 18.2/10,000 is close to the contemporaneous (1999) National Statistics mental health survey which discovered a rate of 0.2% for 11 to 15 year olds, but for the 5 to 10 year olds (although diagnosis would be highly incomplete) it was already 0.4%, while being monitored by the same services.

Already Fombonne was arguing not very persuasively - if you were on the ground - that there was no real change, but just changes in criteria, substitution, whatever, and this is continuous with the accounting strategies of the present, although PDD was itself already the broadest criterion and that was 19 year ago. But now we are looking at conservative estimates of 250/10,000 [3,4] and still no emergency? It should be said - although I had much less experience in 2000 - that this is exactly where I thought we would be now if people went on talking like this, and we are. The trend is unremittingly up, and it is the government's own data which tells us this.

[1] John Stone, 'Re: Autism spectrum disorder: advances in diagnosis and evaluation' 27 July, https://www.bmj.com/content/361/bmj.k1674/rr-10

[2] Eric Fombonne, 'The epidemiology of autism: a review', Psychol Med. 1999 Jul;29(4):769-86, https://www.ncbi.nlm.nih.gov/pubmed/10473304

[3] Metzler et al, 'The mental health of children and adolescents in Great Britain' National Statistics 1999, p.33 Table 4.1 'Prevalence of Mental Disorders', Pervasive development disorder is listed under 'less common disorders', http://www.dawba.com/abstracts/B-CAMHS99_original_survey_report.pdf

[4] John Stone, 'Re: Autism spectrum disorder: advances in diagnosis and evaluation', 21 May 2018, https://www.bmj.com/content/361/bmj.k1674/rr

[5] 'Re: Autism spectrum disorder: advances in diagnosis and evaluation: Nothing to see here folks!', 26 July 2018, https://www.bmj.com/content/361/bmj.k1674/rr-8

Mr Stone asks, “ Why does it always fall to me.....”?

My answer is:
1. Thank heavens the BMJ allows awkward questions to be published on the web.
2. Her Majesty’s Govt is a pachyderm. It will not react to minor stimuli.
3. The medical profession today is largely inert.
4. The medical officer of health who was examined and cross-examined by the elected councillors and by the press was consigned to the dustbin of history in 1974.
5. The “community physicians” who were born in 1974 were expected to be the catalysts of change, trouble-makers and then only administrators. Some of them DID do the job, aided by community health councils and a still vigorous press and television (at least in my experience - please check the local and national press and television records).
Then HMG abolished community health councils (they were so awkward to the Establishment).
6. Now we do have Directors of Public Health. Do they, sometimes, listen to their public (such as Mr Stone) and answer their questions? I do not think so. Never have I seen a rejoinder by a director of public health.
7. The psychiatrists (you might think they had an interest in autism) and paediatricians ( you might reasonably suggest, DO have an interest in the causes, the incidence, the increasing incidence of autism) are mute.

Fare thee well, epidemiology.
Fare thee well, public health.

In answer to John Stone, when I say "muscle meats", I am also referring to fish and poultry. These days, they too are generally eaten without the bones (that used to be tossed into the soup pot instead of the trash), not to mention the likes of shrimp, crab and lobster, of which also only the muscle meats are consumed. And although the consumption of bone broth has now gained some popularity, I think the general shift away from eating it in recent generations is common knowledge. Certainly the overall consumption of meats, fish (including shellfish) and poultry is much higher now in the Western world than in previous generations, and the fact that this results in the depletion of glycine specifically has now been clearly demonstrated in the EPIC-Oxford cohort (1) as I pointed out in my previous response in this string. Perhaps it is unfortunate that those cohort members who consume an omnivorous diet were classified as "meat-eaters", in order to contrast their dietary habits to those who consume no meat or poultry (classified as "fish-eaters"), those who consume no meat, fish or poultry (classified as "vegetarians"), and those who consume no animal products at all ("vegans").

Schmidt JA, Rinaldi S, Scalbert A, et al. Plasma concentrations and intakes of amino acids in male meat-eaters, fish-eaters, vegetarians and vegans: a cross-sectional analysis in the EPIC-Oxford cohort. Eur J Clin Nutrition 2016;70:306–12. doi:10.1038/ejcn.2015.144