The Northern Ireland Department of Health Information Analysis Directorate are to be commended for producing a detailed analysis of the prevalence of autism in schools in the province authored by Iain Waugh [1], the first from any United Kingdom health body I have seen since the middle of the last decade. The results of this survey are unfortunately in line with data I assembled in this column below [2,3,4,5,6].

Below is the most recent of a series of letters I have written posted in on-line British Medical Journal responding to an article by Prof Russell M Viner, President of the Royal College of Paediatrics and Child Health. While Prof Viner was trying to challenge the British government to focus on the health of children and young people, I have been trying to get them both to focus on the tragedy unfolding in our midst: this is the sixth letter since March assembling data from official sources (with much help from Anne Dachel), without a single response. The Northern Ireland Department of Health deserve special praise because all the previous data relating to current autism prevalence in schools comes from education sources. Here at least they recognise and expose the scope of the problem, which represents in greater detail the situation across the United Kingdom. One thing this does is to lay to rest completely the better recognition and diagnosis argument because we actually have here very large numbers of children with extreme levels of disability, not with marginal traits which might have been passed over in the past. In Belfast you are dealing with approaching 3% of the school population who are autistic and with Stage 5 support (the highest level).

The pamphlet records that the rate of diagnosed autism in the province's school has risen from 1.2% of the school population in 2008-9 to 2.9% in 2017 (a leap of 141% and representing a present rate of 1 in 34.5). Also, while the document emphasises that the proportion of complex cases (Stage 5) to the total number of autism cases has declined from 74% to 60%, Stage 5 autism cases have still risen dramatically in relation to the total school population from 0.89% in 2008-9 to 1.74% in 2017-18, i.e. they have nearly doubled and are heading for 2% of the school population.

The pamphlet also records that "children in urban areas were 1 1/2 times more likely to be autistic than those in rural areas" and that autism has become more connected with social deprivation:

"The prevalence of autism in the most deperived [sic] decile (1) has increased by 2.7 precentage

points between 2008/09 and 2017/18, compared to a 1.7 percentage point increase in the

least derpived [sic] decile (10) over the same period of time".

It is presumably a combination of these factors which leads Belfast's schools to have an autism rate of 4.7% (1 in 21 children). The figures will necessarily be incomplete because the younger children are the less likely they are to have yet received a diagnosis. By contrast a National Statistics survey of mental health for the whole of Great Britain in 1999 found a rate of Pervasive development disorder (i.e. the broadest possible definition of autism type conditions) of 0.2% in 11-15 year-olds (ie. 1 in 500 born c.1984-8), who being secondary students were more likely to have received a diagnosis [7].

Of course, the pamphlet only reports, it does not significantly discuss the causes of this catastrophic growth in a type of disability. I fear that whatever it is driving this phenomenon it will be unpalatable to the present generation of paediatricians and health officials, but how much worse does it have to get before they pay attention?

[1] Information Analysis Directorate 'The Prevalence of Autism (including Asperger Syndrome) in School Age Children in Northern Ireland 2018', published 10 May 2018, https://www.health-ni.gov.uk/sites/default/files/publications/health/asd-children-ni-2018.pdf

[2] John Stone, 'Re the NHS must prioritise health of children and young people - what about autism', 19 March 2018, https://www.bmj.com/content/360/bmj.k1116/rr

[3] John Stone, 'The government must face up to the autism pandemic, and so must the RCPCH', 26 March 2018, https://www.bmj.com/content/360/bmj.k1116/rr-0

[4] John Stone, ' Re: The government must face up to the autism pandemic, and so must the RCPCH', 1 April 2018, https://www.bmj.com/content/360/bmj.k1116/rr-2

[5] John Stone, 'The hidden crisis - where are the government and RCPCH, and what is their explanation?' 6 April 2018, https://www.bmj.com/content/360/bmj.k1116/rr-4

[6] John Stone, 'The worst figures of all - 600% rise in additional support in a decade in Scottish schools', 13 April 2018, https://www.bmj.com/content/360/bmj.k1116/rr-5

[7] 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