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Clinical Review State of the Art Review

Autism spectrum disorder: advances in diagnosis and evaluation

BMJ 2018; 361 doi: (Published 21 May 2018) Cite this as: BMJ 2018;361:k1674

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Re: Autism spectrum disorder: advances in diagnosis and evaluation

I have read this review with interest but disquiet [1]. There is perhaps little point in talking about a global prevalence of autism, which Zwaigenbaum and Penner place according to literature at between 1 and 1.5% if autism is rising dynamically in many parts of the world including the United Kingdom - as I have been recently detailing in the columns of BMJ on-line [2]. For instance, recent data from Northern Ireland showed an overall prevalence in schools there of 2.9%, having risen from 1.2% nine years ago, but there are also big disparities between economic classes and town and country, while in Belfast the rate was 4.7% [3,4]. Unfortunately, as Zwaigenbaum and Penner point out diagnosis is characteristically delayed so the true rates are likely much higher.

The rate that be can be established for England from education figures may be at the top end of official estimates at 1.5% but is rising steeply year on year - the rate of Pervasive Development Disorder (the widest possible category of Autistic Spectrum Disorders) for those born between 1984 and 1988 in the United Kingdom was recorded in official data as being 0.2% in 1999. The present figure from Scottish schools data is around 2.2%. However, dramatic reports appear from around the country [2], notably a report from S.W. London where five London boroughs geared to already diagnosing 750 cases a year were confronting almost double that number a year ago . Extrapolated across the capital that might be 10,000 cases a year, which would possibly be in the 10% region [5]. I have argued that still without any officially accepted explanation for this phenomenon - and certainly Zwaigenbaum and Penner provide none - we are on the brink of population catastrophe. They state:

"Lifetime societal costs related to services and lost productivity by patients and their parents average $1.4m (£1.0m; €1.1m) to $2.4m in the United States and £0.9-£1.5m per child in the United Kingdom, depending on comorbid intellectual disability. When the prevalence of ASD is factored in, the annual estimated societal costs of ASD are $236bn in the US and $47.5bn in the UK."

However, most autism parents know from experience that these are very modest or even delusorily low estimates. Even in 2001 Järbrink and Knapp estimated an average lifetime cost per case in the UK as £2.4m (perhaps £3.8m in today's money) though they thought the overall prevalence was 5 in 10,000, which it perhaps still was in the adult population [6].

We come back in the end to the reality that when it comes to what could be driving these changes to our society the authors neither acknowledge the problem, or have any explanation of it. I fear they may be fiddling as Rome burns.

[1] Zwaigenbaum L, Penner M, 'Autism spectrum disorder: advances in diagnosis and evaluation', BMJ 2018; 361 doi: (Published 21 May 2018)
[2] Responses to Viner RM, 'NHS must prioritise health of children and young people',
[3] John Stone, 'Re: NHS must prioritise health of children and young people - 1 in 21 children in Belfast now have an autism diagnosis' 13 May 2018,
[4] Information Analysis Directorate 'The Prevalence of Autism (including Asperger Syndrome) in School Age Children in Northern Ireland 2018', published 10 May 2018,
[5] John Stone, 'Re: NHS must prioritise health of children and young people - what about autism?' , 19 March 2018,
[6] Järbrink K, Knapp M, 'The economic impact of autism in Britain', Autism. 2001 Mar;5(1):7-22.

Competing interests: No competing interests

21 May 2018
John Stone
UK Editor
London N22