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 on the autism spectrum (ASD) 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 individuals with ASD, particularly higher functioning youth. Studies of psychiatric comorbidity in young adults with ASD 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 children and youth with ASD. 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.
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).
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 ASD and those children with more severe impairment (e.g.., intellectual disability).
This study provides important information regarding the risk factors related to suicide in children and youth with ASD. A major finding is that many of the predictors of and variables associated with suicide behavior in adolescent and adult psychiatric and nonpsychiatric samples are also found in children with ASD. 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 ASD 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 children with ASD 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, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson 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 best-selling 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).