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Talking About Death or Suicide: Prevalence and Clinical Correlates in Youth with Autism Spectrum Disorder in the Psychiatric Inpatient Setting

Abstract

Little is known about suicidal ideation in youth with autism spectrum disorder (ASD), making it difficult to identify those at heightened risk. This study describes the prevalence of thoughts about death and suicide in 107 verbal youth with ASD with non-verbal IQ >55, assessed during inpatient psychiatric admission. Per parent report, 22% of youth with ASD had several day periods when they talked about death or suicide “often,” or “very often.” Clinical correlates included the presence of a comorbid mood (OR 2.71, 95% CI 1.12–6.55) or anxiety disorder (OR 2.32, 95% CI 1.10–4.93). The results suggest a need for developmentally appropriate suicide risk screening measures in ASD. Reliable detection of suicidal thoughts in this high-risk population will inform suicide prevention strategies.

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References

  • American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

    Book  Google Scholar 

  • Balfe, M., & Tantam, D. (2010). A descriptive social and health profile of a community sample of adults and adolescents with Asperger syndrome. BMC Research Notes, 3, 300. doi:10.1186/1756-0500-3-300.

    Article  PubMed  PubMed Central  Google Scholar 

  • Bennett, M. (2016). The importance of interviewing adults on the autism spectrum about their depression and suicidal ideation experiences. Journal of Autism and Developmental Disorders, 46(4), 1492–1493. doi:10.1007/s10803-015-2674-4.

    Article  PubMed  Google Scholar 

  • Cash, S. J., & Bridge, J. A. (2009). Epidemiology of youth suicide and suicidal behavior. Current Opinion in Pediatrics, 21(5), 613–619. doi:10.1097/MOP.0b013e32833063e1.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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. Lancet Psychiatry, 1(2), 142–147. doi:10.1016/s2215-0366(14)70248-2.

    Article  PubMed  Google Scholar 

  • Centers for Disease Control and Prevention. (2015). Web-based injury statistics query and reporting system. National Center for Injury Prevention and Control, CDC. Retrieved from http://www.cdc.gov/injury/wisqars/index.html.

  • Gadow, K. D., & Sprafkin, J. (2013) Child and adolescent symptom inventory–4R. Stony Brook, NY: Checkmate Plus.

    Google Scholar 

  • Hannon, G., & Taylor, E. P. (2013). Suicidal behaviour in adolescents and young adults with ASD: Findings from a systematic review. Clinical Psychology Review, 33(8), 1197–1204. doi:10.1016/j.cpr.2013.10.003.

    Article  PubMed  Google Scholar 

  • Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., & Bolte, S. (2016). Premature mortality in autism spectrum disorder. The British Journal of Psychiatry: The Journal of Mental Science, 208(3), 232–238. doi:10.1192/bjp.bp.114.160192.

    Article  Google Scholar 

  • Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., … Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): A brief instrument for the pediatric emergency department. Archives of Pediatrics and Adolescent Medicine, 166(12), 1170–1176. doi:10.1001/archpediatrics.2012.1276.

    Article  PubMed  Google Scholar 

  • Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Hawkins, J., … Zaza, S. (2016). Youth risk behavior surveillance—United States, 2015. MMWR Surveillance Summaries, 65(6), 1–174. doi:10.15585/mmwr.ss6506a1.

    Article  Google Scholar 

  • Klimes-Dougan, B. (1998). Screening for suicidal ideation in children and adolescents: Methodological considerations. Journal of Adolescence, 21(4), 435–444. doi:10.1006/jado.1998.0166.

    Article  PubMed  Google Scholar 

  • Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., & Bishop, S. (2012). Autism diagnostic observation schedule–2nd edition (ADOS-2). Los Angeles: Western Psychological Corporation.

    Google Scholar 

  • Mandell, D. S., Walrath, C. M., Manteuffel, B., Sgro, G., & Pinto-Martin, J. A. (2005). The prevalence and correlates of abuse among children with autism served in comprehensive community-based mental health settings. Child Abuse and Neglect, 29(12), 1359–1372. doi:10.1016/j.chiabu.2005.06.006.

    Article  PubMed  Google Scholar 

  • 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. doi:10.1016/j.rasd.2012.07.009.

    Article  Google Scholar 

  • 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. doi:10.1016/j.rasd.2010.03.006.

    Article  PubMed  PubMed Central  Google Scholar 

  • Mishara, B. L. (1999). Conceptions of death and suicide in children ages 6–12 and their implications for suicide prevention. Suicide and Life-Threatening Behavior, 29(2), 105–118.

    PubMed  Google Scholar 

  • Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30, 133–154. doi:10.1093/epirev/mxn002.

    Article  PubMed  Google Scholar 

  • 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. doi:10.1038/mp.2009.29.

    Article  PubMed  Google Scholar 

  • Office of the Surgeon General & National Action Alliance for Suicide Prevention (2012). Publications and Reports of the Surgeon General 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington (DC): US Department of Health & Human Services (US).

    Google Scholar 

  • Pfeffer, C. R. (1981). Suicidal behavior of children: A review with implications for research and practice. The American Journal of Psychiatry, 138(2), 154–159. doi:10.1176/ajp.138.2.154.

    Article  PubMed  Google Scholar 

  • Raja, M., Azzoni, A., & Frustaci, A. (2011). AUTISM spectrum disorders and suicidality. Clinical Practice & Epidemiology in Mental Health, 7, 97–105. doi:10.2174/1745017901107010097.

    Article  Google Scholar 

  • Roid, G. H., Miller, L., Pomplun, M., & Koch, C. (2013). Leiter international performance scale, third edition (Leiter-3). Torrance, CA: Western Psychological Services.

    Google Scholar 

  • Rutter, M., Bailey, A., & Lord, C. (2003). The social communication questionnaire. Los Angeles: Western Psychological Services.

    Google Scholar 

  • Shtayermman, O. (2007). Peer victimization in adolescents and young adults diagnosed with Asperger’s Syndrome: A link to depressive symptomatology, anxiety symptomatology and suicidal ideation. Issues in Comprehensive Pediatric Nursing, 30(3), 87–107. doi:10.1080/01460860701525089.

    Article  PubMed  Google Scholar 

  • Siegel, M., Doyle, K., Chemelski, B., Payne, D., Ellsworth, B., Harmon, J., … Lubetsky, M. (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. doi:10.1007/s10803-011-1426-3.

    Article  PubMed  Google Scholar 

  • Siegel, M., Smith, K. A., Mazefsky, C., Gabriels, R. L., Erickson, C., Kaplan, D., … Santangelo, S. L. (2015). The autism inpatient collection: Methods and preliminary sample description. Molecular Autism, 6, 61. doi:10.1186/s13229-015-0054-8.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sparrow, S., S., Cicchetti, D. V., &amp, Balla, D. A. (2005). Vineland adaptive behavior scales (2nd ed.). Circle Pines, MN: AGS Publishing.

    Google Scholar 

  • Storch, E. A., Sulkowski, M. L., Nadeau, J., Lewin, A. B., Arnold, E. B., Mutch, P. J., … Murphy, T. K. (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. doi:10.1007/s10803-013-1795-x.

    Article  PubMed  Google Scholar 

  • The Joint Commission. (2016). Detecting and treating suicide ideation in all settings. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf.

  • World Health Organization. (2014). Preventing suicide: A global imperative.

Download references

Acknowledgments

The ADDIRC is made up of the co-investigators: Matthew Siegel, MD (PI) (Maine Medical Center Research Institute; Tufts University), Craig Erickson, M.D. (Cincinnati Children’s Hospital; University of Cincinnati), Robin L. Gabriels, PsyD (Children’s Hospital Colorado; University of Colorado), Desmond Kaplan, MD (Sheppard Pratt Health System), Carla Mazefsky, PhD (Western Psychiatric Institute and Clinics; University of Pittsburgh), Eric M. Morrow, MD, PhD (Bradley Hospital; Brown University), Giulia Righi, PhD (Bradley Hospital; Brown University), Susan L Santangelo, ScD (Maine Medical Center Research Institute; Tufts University), and Logan Wink, MD (Cincinnati Children’s Hospital; University of Cincinnati). Collaborating investigators and staff: Jill Benevides, BS, Carol Beresford, MD, Carrie Best, MPH, Katie Bowen, LCSW, Briar Dechant, BS, Tom Flis, BCBA, LCPC, Holly Gastgeb, PhD, Angela Geer, BS, Louis Hagopian, PhD, Benjamin Handen, PhD, BCBA-D, Adam Klever, BS, Martin Lubetsky, MD, Kristen MacKenzie, BS, Zenoa Meservy, MD, John McGonigle, PhD, Kelly McGuire, MD, Faith McNeil, BS, Joshua Montrenes, BS, Tamara Palka, MD, Ernest Pedapati, MD, Kahsi A.Pedersen, PhD, Christine Peura, BA, Joseph Pierri, MD, Christie Rogers, MS, CCC-SLP, Brad Rossman, MA, Jennifer Ruberg, LISW, Elise Sannar, MD, Cathleen Small, PhD, Nicole Stuckey, MSN, RN, Brittany Troen, MA, R-DMT, Barbara Tylenda, PhD, Mary Verdi, MA, Jessica Vezzoli, BS, Deanna Williams, BA, and Diane Williams, PhD, CCC-SLP. We gratefully acknowledge the contributions of the coordinating site advisory group: Donald L. St. Germain, MD and Girard Robinson, MD, and our scientific advisory group: Connie Kasari, PhD., Bryan King, MD, James McCracken, MD, Christopher McDougle, MD, Lawrence Scahill, MSN, PhD, Robert Schultz, PhD and Helen Tager-Flusberg, PhD, the input of the funding organizations and the families and children who participated.

Funding

This work was supported by the Intramural Research Program (ZIA MH002914) of the National Institute of Mental Health of the National Institutes of Health. The Autism Inpatient Collection (AIC) phenotypic database and biorepository is supported by a grant from the Simons Foundation Autism Research Initiative and the Nancy Lurie Marks Family Foundation, (SFARI #296318 to M.S.). Dr. Mazefsky was also supported by the National Institute of Child Health and Human Development (R01HD079512; K23HD060601).

Author contribution

LMH, AT and MS conceptualized and designed the study, provided input for statistical analyses, wrote the first draft of the manuscript, provided critical review and revision of the manuscript, wrote the final manuscript, and approved the final manuscript as submitted. CF conceptualized and designed the study, conducted statistical analyses of the data, provided critical review and revision of the manuscript, and approved the final manuscript as submitted. EL contributed to conceptualizing the study, prepared the data set for analysis, provided input for statistical analyses, provided critical review and revision of the manuscript, and approved the final manuscript as submitted. RG, JAB, CM, and MP contributed to conceptualizing the study, provided critical review and revision of the manuscript, and approved the final manuscript as submitted.

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Correspondence to Lisa M. Horowitz.

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Conflict of interest

Lisa M. Horowitz, Audrey Thurm, Cristan Farmer, Carla Mazefsky, Elizabeth Lanzillo, Jeffrey A. Bridge, Rachel Greenbaum, Maryland Pao and Matthew Siegel declares that they have no conflict of interests.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee 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.

Additional information

Lisa M. Horowitz and Audrey Thurm are the co-first authors.

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Horowitz, L.M., Thurm, A., Farmer, C. et al. Talking About Death or Suicide: Prevalence and Clinical Correlates in Youth with Autism Spectrum Disorder in the Psychiatric Inpatient Setting. J Autism Dev Disord 48, 3702–3710 (2018). https://doi.org/10.1007/s10803-017-3180-7

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  • DOI: https://doi.org/10.1007/s10803-017-3180-7

Keywords

  • Autism spectrum disorder
  • Suicide
  • Inpatient
  • Suicidal ideation
  • Psychiatric patients
  • Screening
  • Autism Inpatient Collection (AIC)