Assessing and Managing Suicide Risk in Autistic Youth: Findings from a Clinician Survey in a Pediatric Psychiatric Emergency Setting

Suicide-Risk Identification Across Developmental and Behavioral Pediatric Practices: A DBPNet Study

OBJECTIVE

To identify variations in practices, facilitators of and barriers to universal suicide screening of children and adolescents with IDDs in pediatric developmental and behavioral health settings.

METHODS

Centers from the Developmental Behavioral Pediatrics Research Network (DBPNet) were invited to describe suicide-screening practices in their developmental-behavioral pediatrics, psychology, and/or psychiatry clinics. A representative per site/specialty was asked to complete surveys (summarized with descriptive statistics) and semi-structured interviews (summarized using thematic analysis) to explore sites' current practices, and barriers/facilitators to screening.

RESULTS

Participants included 34 survey respondents and 21 interviewees. Surveys revealed variation in suicide screening practices across sites; 44.1% of respondents reported that their practice conducts universal screening, but the screening processes varied widely. Interviews identified some facilitators to screening youth with IDD, such as standardizing procedures, training, and having staff available to respond to positive screens. Barriers to universal screening include factors at the patient, family, provider, and system levels. Insufficient mental health care systems, as well as a lack of IDD-specific supports, are significant challenges.

CONCLUSIONS

Despite Joint Commission requirements and specific expertise in behavioral health, sites serving patients with IDD vary widely in how suicide screening is implemented and how positive screens are addressed. Findings offer opportunities to standardize procedures to increase suicide risk identification and response.

The Suicide Assessment Kit-Modified Interview: Development and preliminary validation of a modified clinical interview for the assessment of suicidal thoughts and behavior in autistic adults

The increased prevalence of suicide among autistic people highlights the need for validated clinical suicide screening and assessment instruments that are accessible and meet the unique language and communication needs of this population. We describe the preliminary preregistered psychometric validation of the Suicide Assessment Kit-Modified Interview, in a sample of 98 autistic adults (58% women, 34% men, 7% nonbinary; MAGE = 41.65, SD = 12.96). A four-item negative affect score derived from the Suicide Assessment Kit-Modified Interview demonstrated adequate reliability (ω = 0.796, BCa 95% confidence interval = [0.706, 0.857]), as well as good convergent validity with related measures. Ordinal Suicide Assessment Kit-Modified Interview "categories" (1-5) demonstrated divergent validity (rs = -0.067 to 0.081) and good convergent validity, strongly correlating with mental health (rs = 0.446 to 0.744) and suicide assessment instruments (rs = 0.576 to 0.696). Suicide Assessment Kit-Modified Interview categories showed strong ability to predict participants identified by clinicians as "above low risk" of future suicide attempt (area under the curve = 0.887, posterior Mdn = 0.889, 95% credible interval = [0.810, 0.954], PAUC > 0.8 = 0.976). Suicide Assessment Kit-Modified Interview classifications > "Category 3" provided an observed sensitivity of 0.750 (Mdn = 0.810, [0.669, 0.948], PSe > 0.8 = 0.544) and an observed specificity of 0.895 (Mdn = 0.899, [0.833, 0.956], PSp > 0.8 = 0.995) for "above low risk" status. Our findings indicate that the Suicide Assessment Kit-Modified Interview is a psychometrically strong clinical assessment tool for suicidal behavior that can be validly administered to autistic adults without intellectual disability.Lay AbstractPeople with a diagnosis of autism are at increased risk of death by suicide. There is a need for clinical instruments that are adapted to the needs of autistic people. In this study, we modified and evaluated a clinical suicide interview (Suicide Assessment Kit-Modified Interview) for use with autistic people who do not have an intellectual disability. Autistic people helped us to modify the original version of the instrument by improving the questions, providing explanations for difficult terms or concepts, and recommending that we use different rating scales. Our results support the use of Suicide Assessment Kit-Modified Interview for assessing autistic adults without intellectual disability for suicidal thoughts and behavior. In the future, we will test how well Suicide Assessment Kit-Modified Interview works in clinical settings and with different clinical populations.

Patients with Autism Spectrum or Intellectual Disability in the Psychiatric Emergency Department: Findings from a 10-year Retrospective Review

PURPOSE

There is a dearth of information about patients with autism spectrum disorder (ASD) or intellectual disability (ID) who seek emergency psychiatric care. Given this backdrop, this retrospective study aims to explore clinical, demographic, and disposition-related information about this patient population over a 10-year period.

METHODS

This study includes individuals with ASD or ID (n = 1461) and had presented to a psychiatric emergency department between 2012 and 2021. Data were extracted using a structured chart review methodology, and included demographic, clinical and visit information. Bivariate and multivariate logistic regressions were estimated to explore associations between key variables and dispositions of interest.

RESULTS

Sample was predominantly White (77.21%), adolescent (mean age ± SD = 15.5 ± 4.3) and male (72.76%). The most common reason for their presentation was aggression towards others (36.39%). 28.27% of patients were psychiatrically hospitalized but 30% of those who needed hospitalization were discharged due to lack of inpatient bed availability.

CONCLUSION

This study adds to the limited literature about individuals with ASD or ID seeking emergency care. The results indicate a highly acute patient population with aggression, suicidal thoughts, and self-injurious behaviors who are frequently prescribed psychotropic medications and face barriers to accessing higher levels of care.

Suicidal Thoughts and Behaviors in People on the Autism Spectrum

PURPOSE OF REVIEW

This review synthesizes recent research on suicidal thoughts and behaviors among autistic individuals. We present literature on risk and protective factors, risk assessment, intervention, and crisis services, and recommendations for future research.

RECENT FINDINGS

Literature on this topic has grown substantially in recent years. Areas of advancement include improved understanding of risk factors (e.g., Interpersonal Theory of Suicide constructs, autistic burnout, mental health conditions, cognitive factors, diagnosis timing, emotion dysregulation), screening, assessment, acute-care services, and suicide-specific psychosocial treatments (e.g., safety planning, dialectical behavior therapy). Gaps include protective factors, impact of intersectional identities, and tailored approaches to screening, assessment, and intervention. Heightened awareness of suicide risk in autistic individuals has led to increased understanding of why autistic individuals think about and attempt suicide and the strategies used to identify and reduce suicide risk. We recommend community-partnered, multi-faceted, and strength-based approaches to inform tailored prevention and intervention efforts.

Improving Emergency Department Care for Suicidality in Autism: Perspectives from Autistic Youth, Caregivers, and Clinicians

ABSTRACT: Purpose: Emergency department (ED) visits for suicidal ideation and self-harm are more prevalent in autistic than non-autistic youth. However, providers are typically offered insufficient guidance for addressing suicide risk in autistic youth, likely impacting confidence and care.

METHODS

In this pilot study, we conducted semi-structured interviews with 17 key members of the autism community (i.e., autistic youth with a history of suicidality, caregivers of autistic youth with a history of suicidality, autism specialist clinicians, ED clinicians) to inform the development of recommendations for modifying ED care for autistic patients, with a focus on suicide risk screening and management.

RESULTS

Participants reported on challenges they encountered receiving or providing care and/or recommendations for improving care. Participant perspectives were aligned, and four main categories emerged: accounting for autism features, connection and youth engagement in care, caregiver and family involvement, and service system issues.

CONCLUSION

As research continues in the development of autism-specific suicide risk assessment tools and management strategies, it is essential we better equip providers to address suicide risk in autistic patients, particularly in ED settings.

Mental health service availability for autistic youth in New York City: An examination of the developmental disability and mental health service systems

LAY ABSTRACT

Autistic children and adolescents experience high rates of co-occurring mental health conditions, including depression and suicidality, which are frequently identified by stakeholders as treatment priorities. Unfortunately, accessing community-based mental health care is often difficult for autistic youth and their families. The first obstacle families confront is finding a provider that offers mental health treatment to autistic youth within the many service systems involved in supporting the autism community. The mental health and developmental disability systems are two of the most commonly accessed, and previous work has shown there is often confusion over which of these systems is responsible for providing mental health care to autistic individuals. In this study, we conducted a telephone survey to determine the availability of outpatient mental health services for autistic youth with depressive symptoms or suicidal thoughts or behaviors in New York City across the state's mental health and developmental disability systems. Results showed that while a greater percentage of clinics in the mental health system compared with in the developmental disability system offered outpatient mental health services to autistic youth (47.1% vs 25.0%), many more did not offer care to autistic youth and there were very few options overall. Therefore, it is important that changes to policy are made to increase the availability of services and that mental health care providers' knowledge and confidence in working with autistic youth are improved.

Suicidal ideation and intentional self-inflicted injury in autism spectrum disorder and intellectual disability: An examination of trends in youth emergency department visits in the United States from 2006 to 2014

LAY ABSTRACT

Youth suicide is a major problem in the United States and globally, but little is known about suicide risk in autistic youth and youth with intellectual disability specifically. Using data from the National Emergency Department Sample, which is the largest database of emergency department visits in the United States, we found that emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis were more common in autistic youth and youth with intellectual disability than in youth without these diagnoses (i.e. the comparison group). This was true when examining both suicidal ideation diagnoses and intentional self-inflicted injury diagnoses at emergency department visits. In addition, the number of emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis increased more from 2006 to 2014 in autistic youth and youth with intellectual disability compared with the comparison group. We also found both similarities and differences when examining factors, such as age, sex, and co-occurring mental health conditions, related to emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis across groups that may be helpful for understanding suicide risk. It is urgent that we improve our understanding, assessment, and treatment of suicidality and self-harm in these groups through more research and clinical efforts.