Talking about Death or Suicide: Prevalence and Clinical Correlates in Youth with Autism Spectrum Disorder

Background: Recent studies suggest that youth with Autism Spectrum Disorder (ASD) are at heightened risk for suicide, but these symptoms often go undetected (Bennett, 2016; Ludi et al., 2012). A significant barrier to accurately detecting suicide risk in ASD is a gap in knowledge about how suicidal thoughts are expressed in youth with ASD. Filling this gap is critical to inform suicide prevention strategies.

Objectives: To describe the prevalence of thoughts about death or suicide in a psychiatric inpatient sample of children and adolescents with ASD, with a range of intellectual ability and co-occurring psychiatric diagnoses, in order to inform suicide prevention strategies.

Methods: A parent reported item from the Child and Adolescent Symptom Inventory-5 (CASI-5), inquiring whether the youth recently "has periods lasting at least several days where he/she talks about death or suicide," was used to estimate prevalence of thoughts about death or suicide for 107 verbally fluent youth (nonverbal IQ >55, ages 10-18 years) with ADOS-confirmed ASD admitted a specialized psychiatric hospital unit (the Autism Inpatient Collection (AIC)). Consensus diagnoses for co-occurring psychiatric disorders were made by a child psychiatrist and unit clinician with expertise in assessment of co-occuring psychopathology in ASD.

Results: Per parent report, 23% of youth with ASD talked about death or suicide "often" or "very often." Clinical correlates included the presence of co-occurring depression (OR=2.71, 95% CI 1.12-6.55) or anxiety disorders (OR = 2.32, 95% CI 1.10-4.93). Demographic factors, including NVIQ, sex, race, and age, were not significantly associated with talking about death or suicide (p>.05).

Conclusions: Talking about death or suicide was a common occurrence in verbally fluent youth with ASD admitted to inpatient psychiatric units. The principal factors related to talking about death or suicide were depressive and anxiety disorders. This was particularly notable because youth with ASD are most frequently admitted to psychiatric hospital units due to externalizing behaviors, such as aggression toward others and property destruction, rather than internalizing problems (Siegel et al., 2011). As prior research has highlighted the under-reporting of suicidal thoughts in typically developing youth, our results may also be an underestimate. Screening for suicidal thoughts in this population can be confounded by some of the challenges inherent to ASD. This includes, but is not limited to, difficulty in identifying self-states, having restricted interests in morbid or negative topics, and displaying deficits in social pragmatics when making suicidal statements to gain attention or escape demands. These challenges and the high prevalence reported here suggest an urgent need for developmentally appropriate suicide risk screening measures for youth with ASD to inform suicide prevention strategies.