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Autism and Suicide

Abstract and Keywords

This article reviews the changes in the autism spectrum disorder (ASD) diagnosis in the Diagnostic Statistical Manual (DSM)-5. It reviews the risk factors associated with suicide in the general population and the link between these risk factors and individuals on the autism spectrum. When discussing autism and suicide (as a spectrum), the complexities that the two present influence parents, researchers, and practitioners. As an added dimension of convolution, there are only a small number of published studies in the area of autism and suicide, and many have marked the importance of awareness and connection between autism and suicide. The article presents the most recent and available research on ASDs and suicide. Methodological challenges related to these studies will be discussed as well as the implications for research, practice, and education.

Keywords: autism, autism spectrum disorders (ASDs), suicide, suicidal behavior, assessment

Introduction

The investigation of suicide among individuals diagnosed with autism or autism spectrum disorders (ASDs) has been given increased attention in recent years. The complexity of suicide as a phenomenon has been widely discussed and explored. One of the challenges in investigating suicide has to do with the spectrum of what is considered suicide. The continuation is from mild and infrequent thoughts to behaviors that include attempts and completion. Suicide is also considered the second leading cause of death worldwide in those 10–24 years of age (Hawton, Saunders, & O’Connor, 2012). Intentional self-harm usually starts in the teenage years and comprises cutting, burning, and slashing (Van der Kolk, Perry, & Herman, 1991). Suicidal actions are considered on a range of progressive seriousness, which includes beliefs, contemplation, threats, attempts, and completions (Foreman, 1990). Suicidal ideation can be considered a precursor to suicidal behavior. The relationship between suicidal ideation, suicidal attempts, and completed suicides is complex. Because it seems reasonable to argue that suicidal ideation precedes any act of self-harm, both suicidal attempts and completed suicides represent subsets of suicidal ideation. The concrete planning of suicide and the availability of means serve as potential risk factors for elevated levels of suicidal ideation. The most common method of research on risk factors for suicide is a technique called “psychological autopsy” (Pelkonen & Marttunen, 2003). In this procedure, researchers reconstruct the life history, behaviors, and social and psychological characteristics of the deceased by interviewing people who knew him or her (Pelkonen & Marttunen, 2003).

Autism spectrum disorders (ASDs) are a cluster of lifelong developmental disabilities caused by an abnormality of the brain (Shtayermman, 2013). ASD is also considered a developmental disorder with different degrees of impairment and variations in symptoms, and the diagnosis is typically made before three years of age. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013) is the source of the most widely accepted nomenclature used by clinicians and researchers for the classification of mental disorders. The DSM has evolved significantly over the years in the way in which ASDs are observed, assessed, and measured. It is imperative to review how autism evolved throughout the years and where ASD as a diagnosis stands today.

Autism was first introduced in the DSM-III (American Psychiatric Association, 1980) as a pervasive developmental disorder (PDD) to convey that individuals with these conditions suffered from impairment in development and multiple areas of functioning. It was suggested that individuals diagnosed with ASD tend to have communication deficits, such as responding inappropriately in conversations, misreading nonverbal interactions, or having difficulty building friendships appropriate to their age. In addition, people with ASD may be overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items. Again, the symptoms of people with ASD fall on a continuum, with some individuals showing mild symptoms and others having much more severe symptoms.

ASD and the DSM

In the DSM-I (1952) and DSM-II (1968), there was no term for autism or PDD. The closest term to autism in the DSM-I and DSM-II was schizophrenic reaction (childhood type). In 1980, the DSM-III included the term PDD: childhood-onset PDD, infantile autism, atypical autism. In 1987, the DSM-III-R (3rd ed., rev.; American Psychiatric Association, 1987) modified the terms to include PDDs: PDD-NOS, autistic disorder. The publication of the DSM-IV in 1994 (American Psychiatric Association, 1994) introduced the spectrum as we knew it up until recently, which included PDD: PDD-NOS, autistic disorder, Asperger disorder, childhood disintegrative disorder, Rett syndrome. In 2000 when the DSM-IV-TR (4th ed., text rev.; American Psychiatric Association, 2000) was published, we the same diagnoses were retained.

ASD in DSM-5

Under the new DSM-5 criteria, individuals with ASD must show symptoms from early childhood, even if they are not recognized until later. This criteria change encourages earlier diagnosis of ASD but also allows people whose symptoms may not be fully recognized until social demands exceed their capacity to receive the diagnosis. For example, if they are at a young age when they do not interact with peers and have no need for social interactions, social challenges as a result of social demand may not be visible. Recently, the published DSM-5 criteria were tested in real-life clinical settings as part of DSM-5 field trials, and the analysis from that testing indicated that there would be no significant changes in the prevalence of the disorder when multiple criteria for diagnosis are implemented.

The following specific changes were implemented in the DSM-5’s new ASD diagnosis:

  • Change number 1: Delete the term PDDs

    • Symptoms are not pervasive—they are specific to the social-communication domain plus restricted, repetitive behaviors/fixated interests

    • Overuse of PDD-NOS leads to diagnostic confusion (and may have contributed to the autism “epidemic”)

    • Overlap of PDD-NOS and Asperger disorder

  • Change number 2: Deletion of childhood disintegrative disorder

    • New knowledge that developmental regression in ASD is a continuous variable, with wide range in the timing and nature of the loss of skills as well as the developmental milestones that are reached prior to regression

  • Change number 3: Elimination of Asperger syndrome

    • New diagnosis in the DSM-IV with little difference from autism

    • Criteria used in the DSM-IV do not match the original cases described by Asperger (his cases meet autism criteria)

    • No clinical or research evidence for the separation of Asperger disorder from autism (high-functioning autism = Asperger diagnosis)

    • Diagnostic biases apparent, with rich, white males receiving Asperger diagnosis, while poorer, non-Caucasian populations receive PDD-NOS diagnosis

  • Change number 4: Merging of ASDs into a single diagnosis

    • Justification

      • Scientific evidence and clinical practice show that a single spectrum better reflects the symptom presentation, time course, and response to treatment

      • The separation of ASD from typical development is reliable and valid, while the separation of disorders within the spectrum is not (e.g., Asperger and are PDD-NOS used interchangeably, as are HFA and Asperger)

      • Many states provide services for the diagnosis of autism; as expected, PDD-NOS and Asperger disorders are rare diagnoses in those jurisdictions

  • Change number 5: THREE will become TWO

    • A social-communication domain will be created by the merger of key symptoms from the DSM-IV social and communication domains

    • Fixated interests and repetitive behavior or activity

      • Justification: Deficits in communication are intimately related to social deficits. The two are manifestations of a single set of symptoms that are often present in differing contexts. This also corrected the “double counting” problem of counting and measuring symptoms presented in the previously listed domains of social and communication issues

        1. A. The new DSM-5 diagnostic criteria for ASD are persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive):

      • Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and the failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions

      • Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and the use of gestures; to a total lack of facial expressions and nonverbal communication

      • Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to an absence of interest in peers

        1. B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):

          • 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases)

          • 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal and nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day)

          • 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest)

          • 4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)

        2. C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)

        3. D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

The DSM-5 also made some adjustments in relation to the language that was used to describe the symptoms associated with ASD

One of the other unique aspects of the DSM-5 relates to the recommendations to include higher-order impairments of “difficulties adjusting behavior to suit different social contexts.” Specifically, the new definition includes a new hierarchy of functioning included in the diagnosis:

Level 1: “Requiring Support”

Level 2: “Requiring Substantial Support”

Level 3: “Requiring Very Substantial Support”

Under each level, there are severity indicators related to social communication and restricted and repetitive behavior. Under each of the above levels there are severity indicators related to two aspects of functioning (see Figure 1, Table 1).

Autism and SuicideClick to view larger

Figure 1. Relationship between the level of support and the domains of assessment.

Table 1. Severity Levels Associated with ASD

Level

Social Communication

Restricted and Repetitive Behavior

Level 1

Without supports in place, deficits in social communication cause noticeable impairments, difficulty initiating social interactions, and clear examples of atypical or unsuccessful response to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-from conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.

Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Level 2

Marked deficits in verbal and nonverbal social communication skills, social impairments apparent even with supports in place, limited initiation of social interactions, and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication.

Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action.

Level 3

Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches.

Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.

Note:

(*) According to the DSM-5 (APA, 2013, p. 52).

An example in the adjustment in the language is the following: a DSM-IV checklist item is “failure to develop peer relationships and abnormal social play,” while the DSM-5 recommendations include higher-order impairments of difficulties adjusting behavior to suit different social contexts. For criterion C, the DSM-IV required that symptoms begin before three years of age. The DSM-5 requires that symptoms begin in early childhood, with the caveat that symptoms may not be fully manifested until social demands exceed capacity (during middle school years, later adolescence, or young adulthood).

New ASD Diagnostic Criteria: New Challenges

The new definition of autism has brought up several concerns for researchers, practitioners, parents, and individuals on the spectrum. From a research perspective, the challenges are now to attempt and capture the spectrum using new evaluation and assessment tools (Risha, Fahed, Khoury, & Mishara, 2014). The new assessment tools also ask us to re-examine the spectrum as we know it and explore the new definition in relation to the previous ones. From a practice perspective, practitioners will begin to change the language used to describe individuals on the spectrum and will embark on a more unified definition, which presents less separation between previously existing disorders (e.g., Asperger syndrome, PDD, and autism) and more inclusion on one spectrum of autism. In seeking services and treatment in practice settings, parents are provided with the challenge of learning a new language of the spectrum and obtaining services in the light of a different definition. Schools and other educational facilities providing services to individuals on the spectrum are faced with a new reality with a new diagnosis.

The prevalence of ASD has dramatically changed over the years. As mentioned above, the disorder has evolved through the years within the DSM and received more attention in recent years as we have seen an increase in the rates and challenges presented to practitioners. Still, the diagnosis of ASD is a unique one due to the significant and wide variation in symptoms and abilities of individuals. The enormous spectrum offers significant challenges in the assessment process, and, in addition, the assessment often seems to include a comorbid disorder, which creates issues in practice for both assessment as well as the treatment. Currently, approximately one in 68 children has been identified with ASD, according to estimates from CDC’s Autism and Developmental Disabilities Monitoring (ADDM) Network.

Meta-Analyses Linking Autism and Suicide

As previously mentioned, ASD is a diagnosis that significantly affects the person’s ability to interact with the surrounding. In addition, previous research linked mental health conditions to suicide. According to Segers and Rawana (2014), risk factors for suicide are a combination of individual, relational, community, and societal factors. Risk factors for suicide may be organized within a framework that distinguishes between proximal and distal exposures, and researchers believe this combination of factors constitutes sufficient conditions leading to suicide (Lubin, Glasser, Boyko, & Barell, 2001). Proximal risk factors are more closely related temporally to the suicidal event and may act as precipitators. These proximal risk factors may include stressful life events, such as sudden illness or bereavement, peer victimization, and the availability of a method for committing suicide (Lubin et al., 2001; Mościcki, 1995). Distal risk factors increase vulnerability to proximal risk factors and include psychopathology, personal characteristics, substance abuse, and familial risk factors. Clearly, there should be an acknowledgment of other conceptual frameworks to explore in relation to suicide; however, this one is an inclusive framework, which permits the exploration of significant numbers of variables in the equation. Because there are many risk factors for suicide, here we present only a few of the important and relevant risk factors for suicide among individuals diagnosed with ASD. The above-mentioned information pertaining to the general population is important because we are seeing a recent rise in the literature on autism and suicide from the United States, Europe, and Asia.

If one would consider the spectrum of autism as well as the spectrum of suicidal behaviors, it would create a new set of complexities for practitioners who are serving individuals on the autism spectrum. Table 2 summarizes the 14 published and available studies on suicide in samples of individuals on the autism spectrum, published between the years 1999 and 2015. Recently, Risha et al. (2014) conducted a meta-analysis specifically for studies of autism and suicide. Some of the methodological challenges in appropriately assessing suicide among individuals on the spectrum are related to the assessment and measurement of certain risk factors related to suicide. Difficulties in the assessment of suicide and suicide-related behaviors among individuals diagnosed with ASD result from challenges arising from communication deficits among individuals on the spectrum, comorbidity with other psychiatric conditions, as well as using a uniformed manner to assess suicidal ideation.

Table 2. Studies Linking Autism with Comorbid Disorders and Suicide

Reference

N

Age group (years)

Setting

Outcome Variable

Mouridsen et al. (2008)

341

2–17

Inpatient psychiatric hospital

Mortality risk

Isager et al. (1999)

341

2–17

Inpatient psychiatric hospital

Mortality risk

Hardan and Sahl (1999)

233

3–19

After-school partial hospitalization

Suicidal ideation and behaviors

Balfe and Tantam (2010)

45

13+

General population

Health and social care

Shtayermman (2008)

10

15–24

General population

Suicidal ideation

Mukaddes and Fateh (2010)

37

6–20

Psychiatric unit

Psychiatric diagnosis

Raja, Azzoni, and Frustaci (2011)

26

16–56

Psychiatric unit

Suicidal attempt

Mikami et al. (2009)

94

<20

Hospitalized individuals

Suicide attempt

Mandell et al. (2005)

156

Children

National survey

Suicide behaviors

Gillberg et al. (2010)

120

>18

Population-based survey

Mortality risk

Mayes et al. (2013)

791

1–16

Outpatient psychiatric unit

Suicidal ideation and behaviors

Croen et al. (2015)

1507

≥18

Members of Kaiser Permanente in Northern California (KPNC)

Suicide attempts

Cassidy et al. (2014)

374

adults

Clinic survey data

Suicidal ideation and attempts

Kato et al. (2013)

587

≥18

Inpatient

Suicide attempts

Much of the reporting on suicide and suicidal tendencies is heavily dependent on the use of verbal and communication skills to obtain some information from individuals. Individuals diagnosed with ASD are frequently diagnosed with other symptoms or disorders not part of the ASD diagnosis (Gillberg & Billstedt, 2000; Tantam, 2000). Depressive and anxiety disorders are the most prevalent psychiatric disorders reported among individuals with ASD (Lainhart, 1999). Some reports indicate that psychotic conditions and conduct disorder may also be present in individuals with ASD (Klin, McPartland, & Volkmar, 2005). It is difficult to diagnose depression in individuals with autism because the assessment of depression relies mainly on communication skills. Individuals on the spectrum may not be able to communicate any suicidal thoughts and plans due to their deficits in communication. Essentially, deficits in communication and the existence of comorbid disorders among individuals diagnosed with ASD place them at risk for suicide.

To date, only two meta-analyses have been done reporting on the link between autism and suicide. Hannon and Taylor (2013) indicated that there were only four studies exploring suicide in the population of individuals diagnosed with autism. The analyses included a range of sample sizes from 10 to 182 participants in all four studies. One of the major complexities within these reported studies involved the inclusion of studies related to both ideation and attempts of suicide. It is important to note that when exploring suicidal ideation and suicidal behaviors, there are differences in assessment and treatment protocols, as individuals who attempted suicide once are at a higher risk for attempting suicide again. In either case, when we discuss ideation or behaviors, we incorporate a large spectrum of observations. From a developmental perspective, the analysis included a range of ages from children through young adults. This is a concern, as most suicidal behaviors commence during adolescence and most reports on suicide rely on verbal communication of thoughts. In addition, we usually rely on verbal skills and reports of individuals when reports on suicidal ideation are explored. The summary of the analysis also suggested that the rates of suicidal behaviors in these studies appeared to be similar to the rate among the typically developing population. However, due to the small sample sizes, clinical setting, and communication deficits of individuals on the spectrum, it is reasonable to consider much higher rates than those reported.

In the second meta-analysis (Risha et al., 2014), which included 11 studies reporting suicide among individuals on the spectrum, we encounter similar methodological challenges as in the previous meta-analysis. Table 2 includes the 11 studies reported in the most recent meta-analysis. The second meta-analysis included the four previously reported studies by Hannon and Taylor (2013). The studies included data over a period of 16 years, and the N was between 10 and 791 participants. When exploring the age range of the participants in studies investigating suicide in autism, it is rather wide and includes both children and adolescents. This creates an issue of validity in relation to the severity of the issue within individuals who are the group at highest risk. From all 13 studies included in the meta-analysis (since the 14th was a meta-analysis), we see an age range of 2–20 years. The assessment tools used in this review of studies presented another concern regarding the manner in which the concept of suicide was assessed, measured, and included in the studies. Some of the studies reporting on suicidal behaviors included cases of death versus others examining the presence of ideation related to suicide. Age range was also widely varied and included a spectrum of developmental stages (childhood, adolescence, and adulthood across the life span). An additional methodological concern of the meta-analysis was related to the clinical versus nonclinical setting of the samples, which can influence the accuracy of the data and its applicability. An issue regarding the results reported in the recent meta-analysis is related to severity of symptoms as reported. In clinical settings, we expect to see more severe cases of mental illness and presence of symptoms than in community-based samples. However, it is important to consider the possibility that individuals on the spectrum with social communication difficulties are not able to accurately convey suicide-related risk factors and symptoms that place them at risk for suicide.

Risk Factors for Suicide Among Individuals on the Spectrum

There are four important risk factors for suicide among individuals on the autism spectrum reported in almost all the studies mentioned in Table 2: gender, race, psychiatric conditions (comorbidity), and peer victimization.

Evidence suggested that a higher percentage of males than females is diagnosed with ASD (CDC, 2014a, 2014b). Prior researchers who investigated the prevalence of suicidal ideation and suicidal behavior in the general population found gender differences in the prevalence of suicidal ideation. Some studies found that one fifth of males were reporting suicidal ideation compared to one third of females (Alison, Roeger, Martin, & Keeves, 2001; Linden, Zaske, & Ahrens, 2003; Mazza & Reynolds, 1998) and that males were two times less likely to report suicidal ideation than females (Esposito & Clum, 2003; Hintikka et al., 2001). Other studies found no association between gender and suicidal ideation (Eshun, 2003; Stravynski & Boyer, 2001). These inconsistencies may be due to the different sample characteristics and measures of suicidality. This is an important factor to consider since the anticipated population has more males than females due to the gender ratio of ASD.

In relation to gender, the majority of the studies have found higher rates of suicidality and mortality due to suicide being more common in males (Cassidy et al., 2014; Croen et al., 2015; Gillberg, Billstedt, Sundh, & Gillberg, 2010; Isager, Mouridsen, & Rich, 1999; Kato et al., 2013; Mandell, Walrath, Manteuffel, Sgro, & Pinto-Martin, 2005; Mayes, Gorman, Hillwig-Garcia, & Syed, 2013; Mouridsen, Brønnum-Hansen, Rich, & Isager, 2008; Shtayermman, 2008). According to Mouridsen et al. (2008), suicide is considered a spectrum of behaviors; therefore, it would be important to explore gender differences among individuals on the spectrum who were not successful in completing suicide. In an examination of recent data from Mouridsen et al. (2008) and Gillberg et al. (2010), females were at a higher risk for suicide; however, this was not a consistent finding in the literature. Mandell et al.(2005) also indicated higher rates of suicide among males in the population of individuals on the spectrum who were sexually and physically abused. Cassidy et al. (2014) examined suicidal ideation and attempts and found higher rates among males. Although males are the more prevalent gender among individuals on the spectrum, there are still mixed results regarding the accuracy of the existence of suicidal behaviors among individuals with ASD.

When reviewing the literature regarding suicide and race as a risk factor in the general population, most available data are from samples that are mostly white (Gutierrez, Rodriguez, & Garcia, 2001). Youth suicide rates in the United States have always been higher among whites than among blacks (Berman & Jobes, 1991; Castle, Duberstein, Meldrum, Cooner, & Conwell, 2004). Eight case control studies conducted between 1985 and 2000 yielded data on suicide for only 97 black individuals (Castle et al., 2004), thus making it difficult to draw conclusions about suicide among black people. Suicide death rates among black youth aged 15–19 years old showed the sharpest increase during the period between 1960 and 1987, increasing from 2.9 to 8.9%, representing a 206% increase in the rate of suicide death among black people in this age group (Berman & Jobes, 1991), and there are no recent data with which to compare it. This increase in suicide deaths among blacks was higher than the increase among whites between 1960 and 1987 (Berman & Jobes, 1991). The suicide rate for whites increased from 5.9 to 17.6% during the same period, an increase of 198% (Berman & Jobes, 1991). Research on suicidal ideation among Hispanics indicates that Hispanic adolescents, mostly Mexican Americans, report higher rates of suicidal ideation than whites (Gutierrez et al., 2001). When exploring the racial composition of suicidal behaviors among individuals on the spectrum, we encounter a majority of studies suggesting a higher prevalence among individuals who identify as white (Balfe & Tantam, 2010; Hardan & Sahl, 1999). Many international studies from Europe and Asia also indicate a higher prevalence of suicidal behaviors among white individuals (Balfe & Tantam, 2010; Mouridsen et al., 2008; Mukaddes & Fateh, 2010). Segers and Rawana (2014) also indicated that being black or Hispanic presents a higher risk for suicidal behaviors than being white. The racial risk factor is mentioned in relation to also being a male, being single, and having a lower socioeconomic status.

Perhaps one of the strongest links to suicide among individuals on the spectrum is mental health–related conditions. Both mood and anxiety-related disorders are the most common mental health condition seen among individuals diagnosed with ASD (Shtayermman, 2008). The fact that autism is a disability of a social nature makes mood and anxiety-related conditions an appropriate risk factor to include in research studies. In general, depression is a common mental disorder that encompasses the loss of interest or pleasure, feelings of low self-esteem, disturbing sleep or appetite patterns, low energy, and poor concentration (Linden Zaske, & Ahrens, 2003). Hankin, Abramson, and Siler (2001) noted that depression rises dramatically during adolescence and that the one-year prevalence rates of clinical depression increase from 3 to 18% between the ages of 15 and 18 years. In addition, 25–40% of adolescents report having a depressed mood. Individuals on the autism spectrum may become socially isolated during adolescence and young adulthood due to difficulties in social settings, which can increase the presence of mood-related conditions. Depressed mood is a condition that has been linked to suicide attempts and reattempts (Spirito, Valeri, Boergers, & Donaldson, 2003). The relationship between psychiatric disorders, and particularly depression symptomatology (Alison, Roeger, Martin, & Keeves, 2001; DiFilippo & Overholser, 2000; Ialongo et al., 2004; Olvera, 2001) and depression (Esposito & Clum, 2003; Lynch, Mills, Daly, & Fitzpatrick, 2004; Mazza & Reynolds, 1998; Wild, Flisher, & Lombard, 2004; Yoder, 1999), to suicidal ideation has been well studied in samples of adolescents. Depression symptomatology is the strongest variable associated with suicidal ideation when compared to other variables, such as attachment to a significant parental figure (DiFilippo & Overholser, 2000), family demographics (Esposito & Clum, 2003; Ialongo et al., 2004; Olvera, 2001; Yoder, 1999), hopelessness, social support, and negative life events (Mazza & Reynolds, 1998). As an illustration, in their study, Hardan and Sahl (1999) included a spectrum of mental health conditions based on the DSM-III. The mental health risk factors included in the study were both symptomatic and diagnostic in nature. This is an important variable and component to consider when examining suicide among individuals on the spectrum because no two individuals diagnosed with ASD are alike or present with the same needs, capacities, or challenges. Thus, individuals on the spectrum of autism may present with a certain level of symptomatology but may not meet the diagnostic criteria for a mental health condition. When assessing mental health among individuals diagnosed with ASD, it will be beneficial to examine both symptoms and diagnoses, as symptoms will present differently from diagnosis and vice versa. Some of the reported studies in Table 2 did not indicate whether there was an assessment of symptoms or diagnosis (Balfe & Tantam, 2010; Mayes et al., 2013). Reports from several studies present alarming numbers of between 30 and 90% of individuals diagnosed with ASD having at least one additional psychiatric condition. The concept of the comorbidity of ASD and mental health, especially in relation to suicide, is of high importance. Individuals on the spectrum of autism may already be at risk for suicide due to socio-demographics and the diagnosis of autism. Considering the aforementioned framework (distal and proximal risk factors), it is only fair to suggest that having a mental health diagnosis (mostly mood and anxiety) increases the risk of individuals on the spectrum for suicide.

In recent years, there has been increased attention in the literature to the field of peer victimization or bullying. Recent evidence suggests that bullying and victimization are associated with severe emotional and behavioral problems (Juvonen, Graham, & Schuster, 2003; Sourander, Helstela, Helenius, & Piha, 2000; Willkins-Shurmer et al., 2003). One definition of the term bullying is a blustering, badgering person, particularly one who is cruel to others who are weaker (Flynt & Morton, 2004). Bullying exists when school-age students are exposed repeatedly or over time to a negative action on the part of one or more students (Flynt & Morton, 2004). Although there is an extensive body of literature on bullies and victims, very little attention has been given to how this problem affects children and adolescents with disabilities (Bender, Rosenkrans, & Crane, 1999; Flynt & Morton, 2004; Mishna, 2003). Peer victimization is considered a proximal risk factor for suicidal ideation (Bond, Carlin, Thomas, Rubin, & Patton, 2001; Cleary, 2000; Juvonen et al., 2003; Kaltiala-Heino, Rimpela, Pantanen, & Rimpela, 2000; Kim, Koh, & Leventhal, 2005; Prinstein, Boergers, Spirito, Little, & Grapentine, 2000; Rigby & Slee, 1999; Storch, Brassard, & Masia-Warner, 2003; Storch & Esposito, 2003; Willkins-Shurmer et al., 2003). Individuals who were victimized by their peers were more vulnerable to developing psychological symptoms of depression and anxiety (Bond et al., 2001; Juvonen et al., 2003; Kaltiala-Heino et al., 2000; Storch et al., 2003; Storch & Esposito, 2003; Willkins-Shurmer et al., 2003). Studies conducted in the United States and in other countries have found the prevalence of suicidal ideation among adolescents who were victimized in school to be 23–26% (Cleary, 2000; Kim et al., 2005). Segers and Rawana (2014) noted that peer victimization occurs in a large percentage of people on the autism spectrum and that between 38 and 75% of individuals on the spectrum reported being victimized. This finding is expected, as externalizing behaviors (such as bullying) are associated with suicidal behavior (Mayes, Gorman, Hillwig-Garcia & Syed, 2013). Shtayermman (2008) also found higher rates of peer victimization (overt) in a population of individuals on the spectrum and diagnosed with Asperger syndrome. The social nature of autism as a disability and the deficits in social communication both place individuals on the spectrum at higher risk for suicide than their peers.

Implications for Research, Practice, and Education

It is critical to consider in any future investigation how suicidal thoughts and behaviors are expressed among individuals with unique clinical profiles such as ASD (Segers & Rawana, 2014). It is important for all healthcare providers to be aware of clinical and mental health issues associated with ASD and how they may present differently from typical development. The development of a risk assessment protocol and evaluation for suicidal ideation among individuals with ASD requires attention and future focus of research. For a population at risk of developing comorbid disorders and suicidal ideation, a comprehensive evaluation of risk factors in research would assist in early identification and treatment services provided to individuals on the spectrum. Considering the recent changes to the DSM-5, it will be beneficial to evaluate the association between ASD level 1 and levels of suicidal ideation, as it may be the level most closely related to Asperger syndrome in the previously published DSM-IV-TR. Access to a larger community-based sample may assist in providing a more accurate profile of individuals on the spectrum who may be at risk for suicidal ideation and assist in the generalizability of findings regarding individuals with ASD and the link the diagnosis has to suicidal ideation.

Segers and Rawana (2014) suggested that suicide among individuals diagnosed with ASD needs to be examined separately from typical development to appreciate the complex interplay of ASD traits on factors contributing to the onset of occasions of suicidality. A clear and perhaps obvious recommendation is that a significantly larger volume of research needs to be facilitated and executed to obtain a better understanding of the association between the autism and suicide. It is crucial to obtain accurate prevalence rates to better understand the phenomenon as well as to shed some light on the extent of the social problem and its impact on individuals. While there is no cure for ASDs, there are many ways to prevent and decrease the suicide rates of individuals on the spectrum. Epidemiological research using population-derived samples is essential. Clarifying the link between risk factors for suicide and the presentation of those symptoms among individuals on the spectrum will be useful for assessment and early intervention. The use of similar samples from diverse diagnostic subcategories is vital, considering that ASD encompasses a highly mixed group with varying levels of intellectual and adaptive functioning.

Any implications for practice must be understood in the context of a small nonprobability sample and the wide range of sample attributes, as previously reported. Many findings suggest that individuals diagnosed with ASD may have similar levels of suicidal ideation as neurotypical individuals. The assessment of suicidal ideation and comorbid disorders as part of a treatment plan is vital for the welfare and well-being of individuals diagnosed with ASD. Clinical assessment and intervention should address the specific needs and challenges of each adolescent or young adult diagnosed with ASD, as each may present with different levels of ASD symptomatology and functioning.

Preventive and clinical intervention settings at schools should provide support groups and psychoeducational groups for individuals with ASD and their neurotypical peers for discussions about peer victimization and stigma associated with developmental disabilities. These social factors considerably impact the lives of the individuals diagnosed with ASD and could be crucial to their functioning, as their disability is of a social nature. Treatment interventions should focus on increasing the ability of individuals diagnosed with ASDs to function using spontaneous communication and to have the ability to socially interact in different social settings of their environment. By targeting the social component of the disability, individuals diagnosed with ASDs can gain more self-confidence in social settings and, as a result, will be more likely to establish an independent life.

Current trends in the social work profession are placing a strong emphasis on evidence-based practice in social work education, practice, and research. Therefore, it is vital to teach students in both the undergraduate and graduate levels of social work education about the possible risk factors for suicidal ideation and comorbid disorders in individuals diagnosed with ASD. Both undergraduate and graduate school courses on psychopathology should incorporate findings from studies that examined risk factors for suicidal ideation. Students should learn about the impact the environment has on the well-being of individuals diagnosed with ASD—more specifically, the impact peer victimization and stigma have on the individual and how different the experience may be for an individual diagnosed with a developmental disability such as ASD.

Clinical practice courses, such as clinical social work with individuals and their families or clinical social work with individuals diagnosed with a developmental disability, should incorporate information about the prevalence of suicidal ideation, comorbid disorders, and peer victimization in individuals with ASD. These courses should include discussions of the possible risk factors for suicidal ideation and potential suicide in addition to risk factors for mood and anxiety-related disorders. Discussions should be framed within the context of person-in-environment and emphasize the connection between this perspective and the perspective assessing for suicidal ideation that includes distal risk factors (personal characteristics) and proximal risk factors (environmental factors).

One theory that could further assist in framing discussions about possible risk factors for suicidal ideation is the stigma theory (Scheff, 2005), which is used to explain how the social and psychological self develops as a result of behaviors, perceptions, beliefs, and other signals one receives from the environment. The Human Behavior in the Social Environment sequence (at times referred to as the Human Behavior, Diversity, and Oppression sequence) should include a discussion of risk factors for suicidal ideation and comorbid disorders in individuals diagnosed with ASD. Because ASD is a disability of a social nature, discussion should incorporate how the environment can facilitate protection or increase the risk for suicidal ideation and comorbid disorders.

Considerations for the Future

This article is intended to synthesize the limited available literature on suicide among individuals diagnosed with ASD. A central point to take away from this review is that the limited data available present more questions than answers. Although we do see a trend in the relationship between ASD and suicide in general, many of the current and available reports are presenting challenges in the interpretation of the findings. The risk factors for suicide among individuals on the spectrum are similar in context to those among individuals who do not meet the diagnostic criteria for ASD. Suicidal ideation and behavior may be mostly present among individuals who have the intellectual capacity to execute a suicidal plan. However, one should take into consideration that high-functioning individuals on the spectrum (autism level 1, according to the current diagnosis criteria) may struggle in society and may encounter difficulties functioning in mainstream settings, which can lead to interpersonal difficulties in functioning within their environments. Considering the social justice framework within social work as a profession, increasing our understanding of how suicide is characterized in ASD will inform how such individuals can be managed, treated, and assessed (Segers & Rawana, 2014).

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