A Comparative Study of Suicidality and Its Association with Emotion Regulation Impairment in Large ASD and US Census-Matched Samples

  • Caitlin M. Conner
  • Josh Golt
  • Giulia Righi
  • Rebecca Shaffer
  • Matthew Siegel
  • Carla A. MazefskyEmail author
S.I.: Suicidality and Self-harm in Autism


Evidence suggests increased rates of suicidality in autism spectrum disorder (ASD), but the research has rarely used comparison samples and the role of emotion dysregulation has not been considered. We compared the prevalence of parent-reported suicidality ideation and considered the role of emotion dysregulation in 330 psychiatric inpatient youth with ASD, 1169 community youth with ASD surveyed online, and 1000 youth representative of the US census. The prevalence of suicidal ideation was three and five times higher in the community and inpatient ASD samples, respectively, compared to the general US sample. In the ASD groups, greater emotion dysregulation was associated with suicidal ideation. Implications include consideration of emotion regulation as a potential mechanism and treatment target for suicidality in ASD.


Suicidality Emotion regulation ASD Autism Reactivity Dysphoria 



This study was supported with funding from NICHD R01 HD079512 (CM), the Ritvo-Slifka Award for Innovation in Autism Research (CM), Simons Foundation Autism Research Initiative and the Nancy Lurie Marks Family Foundation (SFARI #296318, M.S.). IAN is a Partnership Project of the Kennedy Krieger Institute and the Simons Foundation. IAN is also partially funded through a Patient-Centered Outcomes Research Institute (PCORI) Award for Development of the National Patient-Centered Clinical Research Network, known as PCORnet.

Author Contributions

Subjects were recruited and data obtained in partnership with the Interactive Autism Network (IAN) Research Database at the Kennedy Krieger Institute, Baltimore, MD. IAN collaborating investigators and staff included: PHL, MD, JKL, MD, MPH, ARM, PhD. Data were also collected in partnership with the Autism and Developmental Disorders Inpatient Research Collaborative (ADDIRC) through use of Autism Inpatient Collection (AIC) data and YouGov. The ADDIRC is made up of the co-investigators: MS, MD (PI) (Maine Medical Center Research Institute; Tufts University), CE, MD (Cincinnati Children’s Hospital, University of Cincinnati), RLG, PsyD (Children’s Hospital Colorado, University of Colorado), DK, MD and RM, MD (Sheppard Pratt Health System), CM, PhD (UPMC Western Psychiatric Hospital, University of Pittsburgh), EMM, MD, PhD (Bradley Hospital, Brown University), GR, PhD (Bradley Hospital, Brown University), SLS, ScD (Maine Medical Center Research Institute, Tufts University), and LW, MD (Cincinnati Children’s Hospital, University of Cincinnati). Collaborating investigators and staff: JB, BS, CB, MD, CB, MPH, KB, LCSW, CC, BS, BD, BS, TF, BCBA, LCPC, HG, PhD, AG, BS, LH, PhD, BH, PhD, BCBA-D, AK, BS, ML, MD, KM, BS, ZM, MD, JM, PhD, KM, MD, FM, BS, JM, BS, TP, MD, EP, MD, KAP, PhD, CP, BA, JP, MD, CR, MS, CCCSLP, BR, MA, JR, LISW, ES, MD, CS, PhD, NS, MSN, RN, BT, PhD, BT, MA, RDMT, MV, MA, JV, BS, and DW, BA. We thank the study staff for the time and energy they dedicated to this work. Special thanks also to the AIC research participants and their families that made this research possible.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the Ethical Standards of the University of Pittsburgh Institutional Review Board and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

10803_2020_4370_MOESM1_ESM.docx (29 kb)
Supplementary file1 (DOCX 28 kb)


  1. Achenbach T, Rescorla LA (2001) Manual for the ASEBA school-age forms and profiles. University of Vermont Research Center for Children, Youth, and Families, Burlington, VTGoogle Scholar
  2. Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review,30(2), 217–237. Scholar
  3. Berthoz, S., & Hill, E. L. (2005). The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder. European Psychiatry,20, 291–298. Scholar
  4. Bird, G., & Cook, R. (2013). Mixed emotions: The contribution of alexithymia to the emotional symptoms of autism. Translational Psychiatry,3(7), e285–e288. Scholar
  5. Blakeley-Smith, A., Reaven, J., Ridge, K., & Hepburn, S. (2012). Parent–child agreement of anxiety symptoms in youth with autism spectrum disorders. Research in Autism Spectrum Disorders,6(2), 707–716. Scholar
  6. Cai, R. Y., Richdale, A. L., Foley, K.-R. R., Trollor, J., & Uljarević, M. (2018a). Brief report: Cross-sectional interactions between expressive suppression and cognitive reappraisal and its relationship with depressive symptoms in autism spectrum disorder. Research in Autism Spectrum Disorders,45, 1–8. Scholar
  7. Cai, R. Y., Richdale, A., Uljarevic, M., Dissanayake, C., & Samson, A. C. (2018b). Emotion regulation in autism spectrum disorder: Where we are and where we need to go. Autism Research,11(7), 962–978. Scholar
  8. Cassidy, S., Bradley, P., Robinson, J., Allison, C., McHugh, M., & Baron-Cohen, S. (2014). Suicidal ideation and suicide plans or attempts in adults with Asperger’s syndrome attending a specialist diagnostic clinic: A clinical cohort study. The Lancet Psychiatry,1(2), 142–147. Scholar
  9. Cassidy, S. A., Bradley, L., Bowen, E., Wigham, S., & Rodgers, J. (2018a). Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review. Autism Research,62, 56–70. Scholar
  10. Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S. (2018b). Risk markers for suicidality in autistic adults. Molecular Autism,9(1), 1–14. Scholar
  11. Centers for Disease Control (2017) QuickStats: Suicide Rates for teens aged 15–19 years, by sex—United States 1975–2015. Morbidity and Mortality Weekly Report, 66(30), 816.
  12. Conner, C. M., Golt, J., Righi, G., Shaffer, R. C., Siegel, M., & Mazefsky, C. A. (in preparation). The influence of emotion dysregulation on outcomes in ASD: Comparison of inpatient ASD, community ASD, and US census-matched youth samples.Google Scholar
  13. Conner, C. M., White, S. W., Beck, K. B., Golt, J., Smith, I. C., & Mazefsky, C. A. (2019). Improving emotion regulation ability in autism: The Emotional Awareness and Skills Enhancement (EASE) program. Autism,23(5), 1273–1287. Scholar
  14. Daniels, A. M., Rosenberg, R. E., Anderson, C., Law, J. K., Marvin, A. R., & Law, P. A. (2012). Verification of parent-report of child autism spectrum disorder diagnosis to a web-based autism registry. Journal of Autism and Developmental Disorders,42(2), 257–265. Scholar
  15. Davey, S., Halberstadt, J., Bell, E., & Collings, S. (2018). A scoping review of suicidality and alexithymia: The need to consider interoception. Journal of Affective Disorders. Scholar
  16. Demirkaya, S. K., Tutkunkardaş, M. D., & Mukaddes, N. M. (2016). Assessment of suicidality in children and adolescents with diagnosis of high functioning autism spectrum disorder in a Turkish clinical sample. Neuropsychiatric Disease and Treatment,12, 2921–2926. Scholar
  17. Duerden, E. G., Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P., et al. (2012). Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders,42(11), 2460–2470. Scholar
  18. Goodwin, M. S., Mazefsky, C. A., Ioannidis, S., Erdogmus, D., & Siegel, M. (2019). Predicting aggression to others in youth with autism using a wearable biosensor. Autism Research, 12(8), 1286–1296. Scholar
  19. Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology,2(5), 271–299.CrossRefGoogle Scholar
  20. Gross, J. J., & Thompson, R. A. (2006). Emotion regulation: Conceptual foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–26). New York: Guilford Press.Google Scholar
  21. Hatkevich, C., Penner, F., & Sharp, C. (2019). Difficulties in emotion regulation and suicide ideation and attempt in adolescent inpatients. Psychiatry Research,271, 230–238. Scholar
  22. Hayes, A. F. (2015). The PROCESS macro for SPSS and SAS.Google Scholar
  23. Hedley, D., Uljarević, M., Wilmot, M., Richdale, A., & Dissanayake, C. (2017). Brief report: Social support, depression and suicidal ideation in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders,47(11), 3669–3677. Scholar
  24. Hedley, D., Uljarević, M., Wilmot, M., Richdale, A., & Dissanayake, C. (2018). Understanding depression and thoughts of self-harm in autism: A potential mechanism involving loneliness. Research in Autism Spectrum Disorders,46, 1–7. Scholar
  25. Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., & Bölte, S. (2016). Premature mortality in autism spectrum disorder. The British Journal of Psychiatry,208(3), 232–238.CrossRefGoogle Scholar
  26. Horowitz, L. M., Thurm, A., Farmer, C., Mazefsky, C., Lanzillo, E., Bridge, J. A., et al. (2018). Talking about death or suicide: Prevalence and clinical correlates in youth with autism spectrum disorder in the psychiatric inpatient setting. Journal of Autism and Developmental Disorders,48(11), 3702–3710. Scholar
  27. Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.Google Scholar
  28. Joshi, G., Wozniak, J., Fitzgerald, M., Faraone, S., Fried, R., Galdo, M., et al. (2018). High risk for severe emotional dysregulation in psychiatrically referred youth with autism spectrum disorder: A controlled study. Journal of Autism and Developmental Disorders,48, 3101–3115. Scholar
  29. Kato, K., Mikami, K., Akama, F., Yamada, K., Maehara, M., Kimoto, K., et al. (2013). Clinical features of suicide attempts in adults with autism spectrum disorders. General Hospital Psychiatry,35(1), 50–53. Scholar
  30. Khor, A. S., Melvin, G. A., Reid, S. C., & Gray, K. M. (2014). Coping, daily hassles and behavior and emotional problems in adolescents with high-functioning autism/Asperger’s disorder. Journal of Autism and Developmental Disorders,44, 593–608. Scholar
  31. Kirby, A. V. (2019). Suicide and autism spectrum disorder: Associated health conditions. In INSAR 2019 pre-meeting on mental health, Montreal.Google Scholar
  32. Kirby, A. V., Bakian, A. V., Zhang, Y., Bilder, D. A., Keeshin, B. R., & Coon, H. (2019). A 20-year study of suicide death in a statewide autism population. Autism Research,12, 658–666. Scholar
  33. Kleiman, E. M., & Liu, R. T. (2013). Social support as a protective factor in suicide: Findings from two nationally representative samples. Journal of Affective Disorders,150(2), 540–545. Scholar
  34. Lai, J. K. Y., Rhee, E., & Nicolas, D. (2017). Suicidality in autism spectrum disorder: A commentary. Advances in Neurodevelopmental Disorders,1(3), 190–195. Scholar
  35. Lee, H., Marvin, A. R., Watson, T., Piggot, J., Law, J. K., Law, P. A., et al. (2010). Accuracy of phenotyping of autistic children based on internet implemented parent report. American Journal of Medical Genetics, Part B: Neuropsychiatric Genetics,153(6), 1119–1126.
  36. Lerner, M. D., Calhoun, C. D., Mikami, A. Y., & De Los, R. A. (2012). Understanding parent–child social informant discrepancy in youth with high functioning autism spectrum disorders. Journal of Autism and Developmental Disorders,42(12), 2680–2692. Scholar
  37. Lipkin, P. H., Rybczynski, S., Ryan, T., & Wilcox, H. (2019). Screening for suicide risk in children with autism and related disabilities in a pediatric autism center. Montreal: In International meeting for autism research.Google Scholar
  38. Loevaas, M. E. S., Sund, A. M., Lydersen, S., Neumer, S.-P., Martinsen, K., Holen, S., et al. (2019). Does the transdiagnostic EMOTION intervention improve emotion regulation skills in children? Journal of Child and Family Studies,28(3), 805–813. Scholar
  39. Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. L. (2012). Autism Diagnostic Observation Schedule-2. Los Angeles: Western Psychological Services.Google Scholar
  40. Maddox, B. B., Trubanova, A., & White, S. W. (2017). Untended wounds: Non-suicidal self-injury in adults with autism spectrum disorder. Autism, 21(4), 412–422. Scholar
  41. 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(1), 109–119. Scholar
  42. Mazefsky, C. A., Yu, L., & Pilkonis, P. A. (2020). Psychometric properties of the Emotion Dysregulation Inventory in a nationally representative sample of youth. Journal of Clinical Child and Adolescent Psychiatry. CrossRefGoogle Scholar
  43. Mazefsky, C. A., Kao, J., & Oswald, D. P. (2011). Preliminary evidence suggesting caution in the use of psychiatric self-report measures with adolescents with high-functioning autism spectrum disorders. Research in Autism Spectrum Disorders,5(1), 164–174. Scholar
  44. Mazefsky, C. A., Borue, X., Day, T. N., & Minshew, N. J. (2014). Emotion regulation patterns in adolescents with high functioning autism spectrum disorder: Comparison to typically developing adolescents and association with psychiatric symptoms. Autism Research,7(3), 344–354. Scholar
  45. Mazefsky, C. A., Day, T. N., Siegel, M., White, S. W., Yu, L., & Pilkonis, P. A. (2018a). Development of the Emotion Dysregulation Inventory: A PROMIS®ing method for creating sensitive and unbiased questionnaires for autism spectrum disorder. Journal of Autism and Developmental Disorders,48(11), 3736–3746. Scholar
  46. Mazefsky, C. A., Yu, L., White, S. W., Siegel, M., & Pilkonis, P. A. (2018b). The Emotion Dysregulation Inventory: Psychometric properties and Item Response Theory calibration in an autism spectrum disorder sample. Autism Research,11(6), 928–941. Scholar
  47. McCauley, E., Gudmundsen, G., Scholredt, K., Martell, C., Rhew, I., Hubley, S., et al. (2016). The adolescent behavioral activation program: Adapting behavioral activation as a treatment for depression in adolescence. Journal of Clinical Child and Adolescent Psychology,45(3), 291–304. Scholar
  48. McMakin, D. L., Siegle, G. J., & Shirk, S. R. (2011). Positive Affect Stimulation and Sustainment (PASS) module for depressed mood: A preliminary investigation of treatment-related effects. Cognitive Therapy and Research,35(3), 217–226. Scholar
  49. Miller, A. B., McLaughlin, K. A., Busso, D. S., Brueck, S., Peverill, M., & Sheridan, M. A. (2018). Neural correlates of emotion regulation and adolescent suicidal ideation. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging,3(2), 125–132. Scholar
  50. Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. Journal of Consulting and Clinical Psychology,76(1), 28–38. Scholar
  51. Nock, M. K., Hwang, I., Sampson, N. A., & Kessler, R. C. (2010). Mental disorders, comorbidity and suicidal behavior: Results from the National Comorbidity Survey Replication. Molecular Psychiatry,15(8), 868–876. Scholar
  52. Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., et al. (2013). Prevalence, correlates and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). JAMA Psychiatry,70(3), 1–24. Scholar
  53. O’Connor, R. C. (2011). The integrated motivational–volitional model of suicidal behavior. Crisis,32(6), 295–298. Scholar
  54. O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. The Lancet Psychiatry,1(1), 73–85. Scholar
  55. Raja, M., Azzoni, A., & Frustaci, A. (2011). Autism spectrum disorders and suicidality. Clinical Practice and Epidemiology in Mental Health,7(1), 97–105. Scholar
  56. Richa, S., Fahed, M., Khoury, E., & Mishara, B. (2014). Suicide in autism spectrum disorders. Archives of Suicide Research,18(4), 327–339. Scholar
  57. Rutter, M., Bailey, A., & Lord, C. (2003). The Social Communication Questionnaire. Los Angeles: Western Psychological Services.Google Scholar
  58. Samson, A. C., & Antonelli, Y. (2013). Humor as character strength and its relation to life satisfaction and happiness in Autism spectrum disorders. Humor,26(3), 477–491. Scholar
  59. Samson, A. C., Huber, O., & Ruch, W. (2013). Seven decades after Hans Asperger’s observations: A comprehensive study of humor in individuals with Autism Spectrum Disorders. Humor,26(3), 441–460. Scholar
  60. Samson, A. C., Hardan, A. Y., Lee, I. A., Phillips, J. M., & Gross, J. J. (2015). Maladaptive behavior in autism spectrum disorder: The role of emotion experience and emotion regulation. Journal of Autism and Developmental Disorders,45(11), 3424–3432. Scholar
  61. Segers, M., & Rawana, J. (2014). What do we know about suicidality in autism spectrum disorders? A systematic review. Autism Research,7(4), 507–521. Scholar
  62. Shaffer, R. C., Wink, L. K., Ruberg, J., Pittenger, A., Adams, R., Sorter, M., et al. (2019). Emotion regulation intensive outpatient programming: Development, feasibility, and acceptability. Journal of Autism and Developmental Disorders,49(2), 495–508. Scholar
  63. Siegel, M., Doyle, K., Chemelski, B., Payne, D., Ellsworth, B., Harmon, J., et al. (2012). Specialized inpatient psychiatry units for children with autism and developmental disorders: A United States survey. Journal of Autism and Developmental Disorders,42(9), 1863–1869. Scholar
  64. Siegel, M., Smith, K. A., Mazefsky, C., Gabriels, R. L., Erickson, C., Kaplan, D., et al. (2015). The autism inpatient collection: Methods and preliminary sample description. Molecular Autism,6(61), 1–10.
  65. Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan, K., Holland, K. M., et al. (2018). Vital signs: Trends in state suicide rates—United States, 1999–2016 and circumstances contributing to suicide—27 States, 2015. Morbidity and Mortality Weekly Report, 67(22), 617–624. Scholar
  66. Storch, E. A., Sulkowski, M. L., Nadeau, J., Lewin, A. B., Arnold, E. B., Mutch, P. J., et al. (2013). The phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with autism spectrum disorders. Journal of Autism and Developmental Disorders,43(10), 2450–2459. Scholar
  67. Stratis, E. A., & Lecavalier, L. (2017). Predictors of parent–teacher agreement in youth with autism spectrum disorder and their typically developing siblings. Journal of Autism and Developmental Disorders,47(8), 2575–2585. Scholar
  68. Van Eck, K., Ballard, E., Hart, S., Newcomer, A., Musci, R., & Flory, K. (2015). ADHD and suicidal ideation: The roles of emotion regulation and depressive symptoms among college students. Journal of Attention Disorders,19(8), 703–714. Scholar
  69. Volkaert, B., Wante, L., Vervoort, L., & Braet, C. (2018). ‘Boost Camp’, a universal school-based transdiagnostic prevention program targeting adolescent emotion regulation; evaluating the effectiveness by a clustered RCT: A protocol paper. BMC Public Health,18(1), 1–14.CrossRefGoogle Scholar
  70. Weiner, L., Flin, A., Causin, J., Weibel, S., & Bertschy, G. (2019). A case study of suicidality presenting as a restricted interest in autism spectrum disorder. BMC Psychiatry,19(126), 1–5. Scholar
  71. Weiss, J. A. (2014). Transdiagnostic case conceptualization of emotional problems in youth with ASD: An emotion regulation approach. Clinical Psychology: Science and Practice,21, 331–350.Google Scholar
  72. Weiss, J. A., Thomson, K., Burnham Riosa, P., Albaum, C., Chan, V., Maughan, A., et al. (2018). A randomized waitlist-controlled trial of cognitive behavior therapy to improve emotion regulation in children with autism. Journal of Child Psychology and Psychiatry,59(11), 1180–1191. Scholar
  73. Williams, J. M. G., & Williams, M. (1997). Cry of pain: Understanding suicide and self-harm. New York: Penguin Group.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  • Caitlin M. Conner
    • 1
  • Josh Golt
    • 1
  • Giulia Righi
    • 2
    • 3
    • 4
  • Rebecca Shaffer
    • 5
    • 6
  • Matthew Siegel
    • 7
  • Carla A. Mazefsky
    • 1
    Email author
  1. 1.Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Department of Psychiatry and Human BehaviorWarren Alpert Medical School of Brown UniversityProvidenceUSA
  3. 3.Emma Pendleton Bradley HospitalProvidenceUSA
  4. 4.Division of Biology and Medicine, Rhode Island Consortium for Autism Research and Treatment (RI-CART), and the Hassenfeld Child Health Innovation Institute (HCHII)Brown UniversityProvidenceUSA
  5. 5.University of Cincinnati College of MedicineCincinnatiUSA
  6. 6.Division of Developmental and Behavioral PediatricsCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  7. 7.Maine Medical Center Research Institute, Spring Harbor HospitalTufts University School of MedicineWestbrookUSA

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