Suicide Risk in Autism
Suicide and suicidal ideation are serious public health problems among youth in the United States. Suicide is the third leading cause of death among individuals between the ages of 10 and 14, and the second leading cause of death among individuals between the ages of 15 and 24. More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease, combined. It is estimated that 1 in 12 high school students may attempt suicide each year and that more than 2 million adolescents aged 12 to 17 suffered a major depressive episode in the past year. Moreover, estimates for suicide deaths in younger age groups tend to be conservative because suicide deaths may be misclassified as accidental or undetermined. The extant research indicates a strong relationship between depression and suicidal ideation or attempts.
Children and youth with autism frequently have co-occurring (comorbid) psychiatric
conditions, with rates significantly higher than would be expected from the
general population. In fact, depression is one of the most common comorbid
conditions observed in autistic individuals, particularly higher functioning
youth. Studies of psychiatric comorbidity in young adults with autism revealed
that a majority had experienced at least one episode of major depression and reported
recurrent major depression. Although depression is frequent in autism, there is
little research available on suicidal ideation and attempts in autistic children and
youth. This knowledge is critical to help identify at-risk children
and target risk factors for intervention in order to reduce and prevent suicide
ideation and attempts.
Research
Experts agree that much
needs to be learned about suicide ideation and attempts, depression, and other
psychiatric comorbidities in ASD. A study published in Research in Autism Spectrum
Disorders examined the frequency of suicide ideation and attempts, as
well as risk factors in 791 children with autism (1–16 years), 35 depressed
children without ASD, and 186 typical children. Mothers rated their
children on a 4-point scale from “not at all a problem” to “very often a
problem” on a 165-item pediatric behavior scale (PBS). Dependent variables were
two items assessing suicide ideation (“talks about harming or killing self”)
and attempts (“deliberately harms self or attempts suicide”). Co-occurring
problems scores on the PBS included teased by peers; behavior problems (e.g.,
disobedient, defiant, and aggressive); mood dysregulation (e.g., explosive, irritable,
and temper tantrums); attention deficit, impulsive; hyperactive, anxious,
depressed, poor peer relationship (e.g., difficulty making friends); psychotic
features (e.g., hallucinations and confusing fantasy and reality); underaroused
(e.g., drowsy and sluggish), eating disturbance (e.g., poor appetite, over
eating, binging, and purging); excessive sleep, sleeping less than normal and
difficulty falling and staying asleep; and somatic complaints (e.g., headaches and
stomachaches).
Results
Data analyses compared scores between the children with autism, depression, and typical development. Age,
IQ, gender, race, socio-economic status (SES), autism severity, teased, and comorbid
psychological problem scores also analyzed to predict children whose mothers
rated suicide ideation or attempts as sometimes to very often a problem versus
never a problem. The results indicated that
the percentage of children with autism who had ideation or attempts was 28
times greater than that for typical children, but less than for depressed
children. For children with autism, four demographic variables (age 10 or
older, minority status, lower SES, and male) were significant risk factors of
suicide ideation or attempts. The majority of children (71%) who had all four
demographic risk factors had ideation or attempts. Comorbid psychological
problems most highly predictive of ideation or attempts were depression, behavior
problems, and being teased or bullied. Almost half of children with these problems had suicide ideation
or attempts. Depression was the strongest single predictor of suicide ideation
or attempts in children with autism with 77% of children with ideation or
attempts considered by their mothers to be depressed. A significant finding was
that there was no difference in the frequency of suicide ideation or attempts
between higher functioning children with autism and those children with more
severe impairment (e.g.., intellectual disability).
Implications
This study provides
important information regarding the risk factors related to suicide in autistic children
and youth. A major finding is that many of the predictors of and
variables associated with suicide behavior in adolescent and adult psychiatric
and non-psychiatric samples are also found in children with autism. For example,
ideation or attempts were associated with behavior problems (disobedient,
defiant, and aggressive), impulsivity, and mood dysregulation (explosive,
irritable, and temper tantrums). Children with these externalizing problems
combined with the internalizing problem of depression are at high risk for
suicide ideation and attempts. Teasing and bullying by peers is a common problem
for children on the spectrum and was reported by a majority of mothers in the
study. Suicide ideation or attempts were three times more frequent in children
who were teased than in those not teased. The finding that the frequency of
suicide ideation and attempts did not differ as a function of severity or IQ also
suggests that many of the correlates of suicide behavior apply across the
entire autism spectrum.
The authors recommend that
all children with autism be screened for suicide ideation or attempts because the
frequency of ideation and attempts is significantly higher than in typical
children and does not differ as a function of autism severity or IQ. This is
especially important for children who have demographic and comorbid risk
factors, including age 10 or older, male, minority status, lower SES, teased,
depressed, impulsive, behavior problems, and mood dysregulation. Practitioners
must fully be aware of the risk of suicide along with preventative and
treatment methods. Addressing suicide in youth relies on prevention techniques
and modification of risk factors, along with therapeutic intervention once
children are identified as at-risk. Evidence-based techniques to reduce
depression and prevent suicide should be incorporated into programs and
services for autistic children who present with risk factors. This should include
interventions aimed at addressing co-occurring problems that may contribute to suicidal
ideation and attempts, such as teasing, depression, behavior problems, impulsivity,
and mood dysregulation. Lastly, future research should investigate other
predictors (e.g., previous attempts, negative life events, family history of
suicide, and biologic and neurochemical variables), which may improve
identification of children at risk for suicide ideation and attempts.
Mayes, S. D., Gorman,
A. A., Hillwig-Garcia, J., & Syed, E. (2013). Suicide ideation and attempts
in children with autism. Research
in Autism Spectrum Disorders, 7, 109-119.
Lee
A. Wilkinson, PhD, is a licensed and nationally certified school
psychologist, and certified cognitive-behavioral
therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and
Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the
Autism Spectrum: A Self-Help Guide Using CBT. He is also
editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and
Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and
Intervention for Autism Spectrum Disorder in Schools (2nd Edition).