The relevance of the interpersonal theory of suicide for predicting past-year and lifetime suicidality in autistic adults

Lifetime stressor exposure is related to suicidality in autistic adults: A multinational study

Despite very high rates of suicidal thoughts and behaviors (STB) in autistic adults, the key psychosocial drivers of this phenomenon remain unknown. To investigate, we examined how lifetime stressor exposure and severity, which have been found to predict STB in non-autistic populations, related to STB in a multinational dataset of 226 autistic adults from the United Kingdom and Australia (67% female; Mage = 41.8, SD = 13.6, range = 19-73 years old). Results revealed that autistic men and women differ with respect to the count, severity, and type of stressors they experienced over the life course. Whereas autistic men were exposed to more numerous legal/crime-related stressors, autistic women experienced more stressors related to social relationships and chronic humiliation and typically experienced stressors as more severe. In addition, whereas chronic interpersonal loss was related to STB for men, acute stressors involving physical danger and lower exposure to chronic entrapment were related to STB in autistic women. These findings indicate that certain lifetime stressors may be differentially experienced, and relevant to STB, in autistic men versus women. They also suggest that screening for lifetime stressor exposure may help identify autistic individuals at greatest risk of suicide.Lay abstractWhen we encounter life events that we experience as stressful ("stressors"), it sets off a biological stress response that can impact mental health and contribute to suicidal thoughts and behaviors (STB). Although we know about specific stressors that are associated with STB in the general population, little is known about the kinds of stressors that increase the risk of STB in autistic people and whether these associations differ by gender. To examine this issue, we cataloged the life stressors that autistic men and women experienced over the entire life course and investigated how these stressors were related to STB. Data were derived from a multinational sample of 226 autistic adults from the United Kingdom and Australia who completed the Stress and Adversity Inventory for Adults. We found that autistic men and women differed in terms of both the lifetime stressors they experienced as well as their perceived severity. Whereas men experienced more legal/crime-related stressors, women experienced more stressors related to relationships with other people and more long-lasting stressors associated with humiliation. Autistic women often perceived life stressors as more severe than men, which is important given that it is the perceived severity of stressors that most strongly affects our health. We also found that different stressors may predict STB in autistic men versus women. Whereas loss of loved ones was most strongly associated with STB for men, for women, physically dangerous stressors were most relevant. In addition, women with fewer lifetime stressors involving entrapment had higher lifetime STB. These results suggest that lifetime stressor exposure may be important to assess to understand suicide risk in autistic people. Additional research is needed to confirm these associations and to examine possible mechanisms linking stress and STB.

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.

(Re)thinking about self-harm and autism: Findings from an online qualitative study on self-harm in autistic adults

LAY ABSTRACT

There is a higher prevalence of self-harming behaviours within the autistic community than is experienced by the general population, in addition to co-occurring mental health conditions such as anxiety and depression. To date, research has focused on quantifying and categorising the numbers of autistic people self-harming, what types of harming they are engaging in and what functions the harming performs. Autism research has historically focused on the opinions and experiences of parents, carers and clinicians, with a belief that autistic people are unable to present their own experiences and thoughts accurately. This study adopted a qualitative method to develop themes arising from online forum discussions, using the words of autistic adults talking about how they experience and understand their self-harming behaviours. The analysis discovered that self-harming behaviours are used by autistic people as a way of coping with anxiety and depression and to relieve the build up of stress and sensory or mental overload that can otherwise lead to a meltdown. Repetitive behaviours such as stimming are also used to relieve the buildup of sensory over-stimulation and anxiety, but both stimming and meltdowns can also be self-harming behaviours if they cause tissue damage, and are believed to be childhood presentations which are stigmatised if expressed by an autistic adult. Many autistic adults find it hard to get help with self-harming behaviours because they are not taken seriously by professionals, as it is seen as part of autism and cannot be helped, or the professionals do not have enough knowledge of autism.

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.

Occurrence and predictors of lifetime suicidality and suicidal ideation in autistic adults

LAY ABSTRACT

Over the past few years, more and more research is showing that many autistic people are at an increased risk for suicide. In this study, we asked participants from the Netherlands Autism Register, which is longitudinal register including individuals with autism, about their possible experiences with thoughts and feelings about suicide. Specifically, we looked at whether these thoughts and feelings in their lifetime and in the past month were related to various factors (such as their age, gender, and having psychiatric disorder diagnoses). We found that 80% of the participants had experienced thoughts about or even attempted to take their own life at least once throughout their lifetime. Furthermore, in a subgroup of participants, we found that the presence of a psychiatric disorder diagnosis, feelings of loneliness, and a higher number of autistic traits were associated with experiencing suicidal thoughts and feelings in their lifetime. For those who experienced these suicidal thoughts in the past month, we found that having (multiple) psychiatric disorder diagnoses and a higher number of autistic traits were related to more severe and frequent thoughts about suicide in the past month. Our findings show that additional factors in autistic individuals should be considered when assessing the suicide risk, and it brings us one step closer to understanding why suicide is more common for autistic people.

Examination of the Potential Moderating Role of Psychological Wellbeing in the Relationship Between Depression and Thoughts of Self-Harm in Autistic Adolescents and Adults: A Two-Year Longitudinal Study

PURPOSE

Autistic people have a significantly increased risk of death by suicide relative to the general population. In non-autistic samples, psychological wellbeing has been shown to moderate the relationship between depression and suicidal thoughts and behavior. Thoughts of self-harm may provide a useful indicator of suicidal risk. In this longitudinal study we examined (a) the potential role for psychological wellbeing to moderate the relationship between depressive symptoms and thoughts of self-harm and (b) the contribution of autistic traits to thoughts of self-harm.

METHODS

Participants were 209 autistic adolescents and adults aged 15 to 80 years (Mage = 34.20, SD = 15.38 years).

RESULTS

At both baseline and 2-year follow-up, 35% of participants reported recent thoughts of self-harm. Wellbeing was associated with autistic traits (r = - .350 to - 0.404) and depression (r = - .480 to - 0.759). Thoughts of self-harm were positively associated with autistic traits and depression (r = .242 to 0.659), and negatively associated with wellbeing (r = - .287 to - 0.609). Controlling for baseline thoughts of self-harm, depression (β = 0.254, p = .001) and autistic traits (β = 0.162, p = .007) significantly predicted thoughts of self-harm at 2-year follow-up.

CONCLUSION

Despite a lack of support for the hypothesis that wellbeing would moderate the relationship between depression and thoughts of self-harm, correlational data demonstrated significant associations between wellbeing and both depression and thoughts of self-harm. Future research considering psychological wellbeing as a potential protective factor for self-harm in autistic people is warranted.

Linehan's biosocial model applied to emotion dysregulation in autism: a narrative review of the literature and an illustrative case conceptualization

Emotion dysregulation (ED) is a transdiagnostic difficulty prevalent in autism spectrum condition (ASC). Importantly, recent research has suggested that ED is involved in self-harm and suicidality. Pre-existing models on the etiology of ED in ASC focus mainly on biological factors to ASC features, such as sensory sensitivities, poor flexibility, and sensitivity to change. However, although psychosocial factors seem to play a role in the emergence of ED in ASC as well (e.g., childhood maltreatment and camouflaging), there is a lack of a comprehensive model conceptualizing biosocial factors involved in ED in autistic people. Linehan's biosocial model (1993) is one of the leading etiological models of ED in borderline personality disorder (BPD). It conceptualizes ED as emerging from transactions between a pre-existing emotional vulnerability in the child and an invalidating developmental environment. Beyond its clinical relevance, Linehan's model has gathered empirical evidence supporting its pertinence in BPD and in other psychiatric disorders. Although ASC and BPD are two distinct diagnoses, because they may share ED, Linehan's biosocial model might be useful for understanding the development of ED in ASC. Hence, this article aims to provide an application and extension of Linehan's model to conceptualize ED in ASC. To do so, we conducted a narrative review of the literature on ED and its underlying factors in ASC from a developmental perspective. To investigate the pertinence of the biosocial model applied to ED in autistic people, we were interested on data on (i) ED and its behavioral correlates in ASC, in relation to the biosocial model, (ii) the potential biological and psychosocial correlates of ED in ASC and (iii) the overlapping difficulties in ASC and BPD. Finally, to assess the pertinence of the model, we applied it to the case of an autistic woman presenting with ED and suicidal behaviors. Our review and application to the case of an autistic woman suggest that ED in ASC encompasses factors related to both biological and psychosocial risk factors as conceptualized in the BPD framework, although in both domains ASC-specific factors might be involved.

A systematic review of predictors of suicidal thoughts and behaviors among autistic adults: Making the case for the role of social connection as a protective factor

Autistic adults are a high-risk population for suicidal thoughts and behaviors (STBs). Accordingly, this systematic review aims to review the prevalence of STBs among autistic adults, review the risk and protective factors for STBs in autistic adults, and formulate a disorder-specific conceptualization of risk in this population. We systematically searched PsycINFO and Google Scholar for all studies published prior to March 28th, 2022. We included empirical articles focused on autistic adults, ages 18 years and older, reporting on suicide-related outcomes. In total, 45 peer-reviewed empirical articles were included in the current systematic review. The most frequently studied factors in relation to suicide risk among autistic adults were interpersonal constructs (42.4% of total studies looking at risk/protective factors) and depressive symptoms (36.4% of total studies looking at risk/protective factors). We conclude by summarize two key content areas: exploring social and interpersonal constructs and better understanding the role of depressive symptoms in autism. As researchers continue to explore STBs among autistic adults, it will be necessary to addressing the overreliance on autistic symptoms instead of autism diagnoses, measurement issues of STBs, and a need for treatment adaptations.