Suicidality in autistic youth: A systematic review and meta-analysis

Risk and Protective Factors of Self-harm and Suicidality in Adolescents: An Umbrella Review with Meta-Analysis

Suicide remains the second most common cause of death in young people aged 10-24 years and is a growing concern globally. The literature reports a vast number of factors that can predispose an adolescent to suicidality at an individual, relational, community, or societal level. There is limited high-level research identifying and understanding these risk and protective factors of adolescent suicidality. The present study used an umbrella review and meta-analysis to synthesize evidence from the review literature in the past 20 years on risk and protective factors of self-harm and suicidality (behavior and ideation) in adolescents. The umbrella review included 33 quantitative reviews with 1149 individual studies on suicidality and self-harm. Based on the data synthesis, it compared the public health impact of exposure on the population of the identified exposure. Bullying victimization was the most attributed environmental exposure for suicidality. The other identified significant school and individual factors were sleeping disturbance, school absenteeism, and exposure to antidepressants. Several significant vulnerable young populations were identified with significantly higher prevalence of suicidality, including lesbian, gay, bisexual, transgender, queer (or questioning) youth and those with mental health disorders, problem behaviors, previous suicidality, self-harm, and gender (female). A person-centered approach emphasizing connectedness and bully-free school environments should be a priority focus for schools, health professionals, and public health policymakers.

Measuring and validating autistic burnout

Researchers have begun to explore the characteristics and risk factors for autistic burnout, but assessment tools are lacking. Our study comprehensively examined and compared the psychometric properties of the unpublished 27-item AASPIRE Autistic Burnout Measure (ABM), and personal and work scales of the Copenhagen Burnout Inventory (CBI) to evaluate their efficacy as screening measures for autistic burnout, with a group of 238 autistic adults. Exploratory factor analyses (EFA) revealed a 4-factor structure for the ABM and a 2-factor structure for the CBI personal scale (CBI-P). Factorial validity and dimensionality were examined with four exploratory models which indicated a unidimensional structure for the ABM with an overarching 'Autistic Burnout' construct, and multidimensional CBI-P structure comprising two subscales and overarching 'Personal Burnout' construct. Other reliability and validity indicators included Spearman correlations, analysis of variance, receiver operating characteristics, sensitivity, specificity, and intra-class correlations (ICC). The ABM and CBI-P were strongly correlated with depression, anxiety, stress, and fatigue. Unexpectedly, correlations between the burnout measures and camouflaging, and wellbeing measures were moderate. Potential overlap between burnout and depression and fatigue was examined through EFA, which supported convergent validity of the ABM and depression measure, while correlations and ICC analyses revealed mixed results. We concluded that the ABM and the CBI-P Emotional Exhaustion subscale were valid preliminary screening tools for autistic burnout. Testing with larger and more diverse autistic samples is required to further examine the psychometric properties of the ABM, and to understand the relationships between autistic burnout and depression, and masking.

Suicidal Thoughts and Behaviors Among Children and Adolescents With Autism Spectrum Disorder

This survey study uses data from the Mental Health and Suicidal Behaviors Questionnaire to examine the age at onset of suicidal thoughts and behaviors among children and adolescents aged 8 to 17 years who have been diagnosed with autism spectrum disorder (ASD).

Mortality and Autism: Suicide and Elopement

Autistic children and youth are at risk for premature mortality. Two preventable causes of that increased risk are elopement and suicide. Pediatricians should educate themselves and caregivers about strategies that could prevent tragic situations involving autistic youth.

Use of ECT in Autism Spectrum Disorder and/or Intellectual Disability: A Single Site Retrospective Analysis

Autism spectrum disorder (ASD) and intellectual disability (ID) are heterogenous and prevalent conditions which may occur in isolation or as a co-morbidity. Psychiatric co-morbidity is common with limited treatment options. Preliminary research into electroconvulsive therapy (ECT) for these conditions has been encouraging. Thus, further research in this patient population is warranted. We conducted a 10-year retrospective review of the electronic medical record and identified intellectually capable individuals with ASD (IC-ASD), and those with ASD+ID or ID who received at least three ECT treatments. 32 patients were identified of which 30 (94%) experienced positive clinical response, defined as a clinical global impression-improvement (CGI-I) score of 3 or less. The average retrospective CGI-I score across all groups was 1.97, and results of a t-test performed on CGI-I scores indicated improvement across all groups [t = - 16.54, df = 31, p < 0.001, 95% CI = (1.72, 2.22)]. No significant adverse events were identified based on clinical documentation. Our findings further support previous ECT research in this patient population.

The Prevalence of Suicidal Behavior in Autism Spectrum Disorder

Background: Suicidal ideation (SI) and suicide attempts (SA) are common in autistic individuals, but prevalence rates have not yet been estimated with meta-analysis. Aims: This meta-analysis aims to estimate SI and SA prevalence rates in autistic individuals and identify subgroup differences based on sample characteristics and study quality. Methods: A systematic search identified 52 studies with 88,509 autistic participants reporting SI and SA. Pooled prevalence estimates were calculated using a random-effects model. Results: Pooled prevalence estimates of lifetime SI and SA were 37.2% [95% CI 25.3-50.8] and 15.3% [95% CI 9.5-23.6], respectively. For 12-month prevalence, this was 25.4% [95% CI 19.0-33.2] and 14.1% [95% CI 7.4-25.2], respectively. Subgroup analyses revealed significant differences based on age (SI), region (SI), data collection (SI), measurement scales used to define autism and suicidality (SA), and representation of the study sample (SI and SA). Heterogeneity measures were high for all outcomes (I2 = 60.3-99.1%). Limitations: The heterogeneity of the included studies may limit the generalizability of our findings. Conclusion: The high rates of suicidal problems in autistic individuals call for a systematic evaluation of suicidality in clinical practice and adequate therapeutic interventions to improve this condition.

Risk of suicide attempt with gender diversity and neurodiversity

There is growing concern about psychiatric illness co-occurring with gender-diversity and neurodiversity, including risk of suicidal behavior. We carried out systematic reviews of research literature pertaining to suicide attempt rates in association with gender- and neurodiversity, with meta-analysis of findings. Rates of suicidal acts ranked: gender-diverse versus controls (20.1% vs. 1.90%; highly significant) > autism spectrum disorder (4.51% vs. 1.00%; highly significant) > attention deficit-hyperactivity disorder (7.52% vs. 4.09%; not significant). Attempt rates also were greater among controls who included sexual minorities (5.35% vs. 1.41%). The rate among male-to-female transgender subjects (29.1%) was slightly lower than in female-to-male subjects (30.7%), who also were encountered 24.3% more often. In sum, suicidal risk was much greater with gender-diversity than neurodiversity. Suicide attempts rate was somewhat greater among female-to-male transgender subjects. Available information was insufficient to test whether suicidal risk would be even greater among persons with both gender- and neurodiversity.

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.

Valence and Intensity of Emotional Expression in Autistic and Non-Autistic Toddlers

PURPOSE

Differences in emotional experience and expression have long been recognized as common in the presentation of autism, yet research examining emotional expression in early childhood is limited, with mixed findings. Understanding emotional reactivity and expression in autism in early life is an essential step towards uncovering the mechanisms of these risks and identifying targets for intervention.

METHODS

The present study examined emotional expression in autistic (N = 17) and non-autistic (N = 20) toddlers (mean age = 25.27; SD = 1.88) during emotion elicitation tasks aimed at eliciting joy, frustration, and unease. Video recorded tasks were coded in ten second intervals for emotional valence and intensity, and the following variables were computed: proportion of time in positive, neutral, and negative affect; maximum intensity of positive and negative affect; and range of affect (i.e., most negative to most positive intensity).

RESULTS

Autistic toddlers spent more time in neutral facial expressions, less time displaying positive affect, and had somewhat less intense positive emotional expression than non-autistic peers. Small differences were apparent in intensity of negative affect expression, while no differences emerged in duration of time spent in negative affect.

CONCLUSION

Findings emphasize that differences may be more apparent in duration, rather than intensity of emotional expression, and that it may be particularly important to examine periods of "neutral" affect in young autistic children. Future research should consider the best ways to understand emotional reactivity in this population considering their unique interests, challenges, and communication styles.

Use of ECT for Children With and Without Catatonia: A Single-Site Retrospective Analysis

OBJECTIVES

The objective study was to investigate the safety and efficacy of electroconvulsive therapy (ECT) in a retrospective cohort of pediatric patients.

METHODS

A single-site retrospective analysis was conducted of patients aged younger than 18 years who received ECT in a private university hospital from January 28, 2012 to April 8, 2023. Treatment efficacy and adverse events were determined retrospectively through review of the medical record.

RESULTS

A total of 36 pediatric patients met the inclusion criteria. Catatonia was the most common presenting indication for ECT, followed by psychosis and suicidal ideation. For all patients, Clinical Global Impressions-Improvement scale scores indicated that it was very likely for a subject to experience at least "much improvement" with the estimated probability of receiving a Clinical Global Impressions-Improvement scale score better than 3 of 0.852 (t.s. = 16.3; P < 0.001; 95% confidence interval, 0.711-0.931). All patients with catatonia demonstrated a positive clinical response and experienced a statistically significant reduction in total Bush-Francis Catatonia Rating Scale scores observed (t = 11.9; df = 20; SD = 6.3; P < 0.001; 95% confidence interval, 12.6-17.9). No significant adverse events were reported for any patient in the cohort. However, 14 (38.9%) patients experienced prolonged seizures, all of which were terminated with propofol (mean, 49.7 mg).

CONCLUSIONS

This study provides further data supporting the safe and effective use of pediatric ECT in the treatment of various psychiatric conditions. However, more research is needed to determine the risk factors associated with prolonged seizures and the optimal seizure parameters in young people.

Treatment Response of Transcranial Magnetic Stimulation in Intellectually Capable Youth and Young Adults with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

To examine current clinical research on the use of transcranial magnetic stimulation (TMS) in the treatment of pediatric and young adult autism spectrum disorder in intellectually capable persons (IC-ASD). We searched peer-reviewed international literature to identify clinical trials investigating TMS as a treatment for behavioral and cognitive symptoms of IC-ASD. We identified sixteen studies and were able to conduct a meta-analysis on twelve of these studies. Seven were open-label or used neurotypical controls for baseline cognitive data, and nine were controlled trials. In the latter, waitlist control groups were often used over sham TMS. Only one study conducted a randomized, parallel, double-blind, and sham controlled trial. Favorable safety data was reported in low frequency repetitive TMS, high frequency repetitive TMS, and intermittent theta burst studies. Compared to TMS research of other neuropsychiatric conditions, significantly lower total TMS pulses were delivered in treatment and neuronavigation was not regularly utilized. Quantitatively, our multivariate meta-analysis results report improvement in cognitive outcomes (pooled Hedges' g = 0.735, 95% CI = 0.242, 1.228; p = 0.009) and primarily Criterion B symptomology of IC-ASD (pooled Hedges' g = 0.435, 95% CI = 0.359, 0.511; p < 0.001) with low frequency repetitive TMS to the dorsolateral prefrontal cortex. The results of our systematic review and meta-analysis data indicate that TMS may offer a promising and safe treatment option for pediatric and young adult patients with IC-ASD. However, future work should include use of neuronavigation software, theta burst protocols, targeting of various brain regions, and robust study design before clinical recommendations can be made.

Considerations for Expanding Research and Clinical Care for the Neurodivergent Gender Diverse Population

Little is currently known about the relationship between gender diversity and neurodiversity, although a growing body of researchers and clinicians are searching for more information to better serve this population. Gender-diverse individuals are three to six times more likely than cisgender individuals to identify as autistic or to report possible undiagnosed autism or autistic traits. Many gender-diverse individuals experience a shortage of gender-affirming medical care and are disproportionately impacted by barriers to mental health services. Similarly, autistic individuals report that the most common barrier to care is a lack of knowledgeable providers and/or resistance from providers to tailor care toward their specific needs. Two key areas in need of further research are 1) clinical approaches to gender-affirming medical and mental health care for neurodivergent patients and 2) the prevention and treatment of suicidality in gender-diverse neurodivergent individuals. Increasing collaborations amongst gender-diverse neurodivergent individuals, researchers, and clinicians are needed in order to further research and clinical practice to most directly and effectively improve physical and mental health care for the gender-diverse neurodivergent patient population.

All-cause mortality and suicide mortality in autistic individuals: An entire population longitudinal study in Taiwan

LAY ABSTRACT

Our study was the first population-based study in an Asian country to investigate the mortality rates among autistic individuals. Among the entire Taiwanese population (N = 29,253,529), between 2003 and 2017, 45,398 autistic individuals were identified and 1:4 age-/sex-matched to 181,592 non-autistic individuals. We found that autistic individuals had increased risks of all-cause mortality, natural-cause mortality, and suicide mortality compared with non-autistic individuals. Furthermore, autistic males were more likely to die by suicide, and autistic females were more likely to die of accident compared with the non-autistic individuals.

Suicidal Risk Behaviors in Adolescents With Rare Neurodevelopmental Disorders: The Role of Sex, Autistic Traits, and Mental Health Difficulties

OBJECTIVE

Autistic traits are associated with mental health difficulties and risk of suicidal risk behaviors among adolescents. Little is known about how autistic traits affect the mental health of adolescents with rare neurodevelopmental disorders (RNDs). The aim of this study was to investigate the relationship between autistic traits, mental health difficulties, and suicidal risk behaviors in adolescents with RNDs.

METHODS

Parents (N = 93) completed the Child Behavior Checklist, Social Communication Questionnaire, and Social Responsiveness Scale about their adolescent (Mage = 13.1, SD = 2.3, 62.4% females) with an RND (e.g., sex chromosome aneuploidies, Fragile X syndrome, 22q11.2 deletion syndrome). The data were analyzed with hierarchical logistic regression analysis.

RESULTS

The prevalence of suicidal risk behaviors (16.1%) was similar to that reported among autistic youth and was higher among boys than girls. More autistic traits were associated with suicidal risk behaviors in bivariate analysis. In multivariate analysis, more anxiety/depressive symptoms were associated with more suicidal risk behaviors and externalizing problems associated with suicidal risk behaviors beyond autistic traits and anxiety/depressive symptoms.

CONCLUSION

Adolescents with RNDs are at risk of suicidal risk behaviors, especially those with higher levels of autistic traits, anxiety/depressive symptoms, and externalizing problems. Assessment of autistic traits, mental health difficulties, and suicide risk may be indicated for adolescents with RNDs to determine if corresponding intervention is needed.

COVID-19 and Neurodevelopmental Disabilities: Examining the Impact of the First 2 Years of the Pandemic on the Demand for Pediatric Inpatient Care

The COVID-19 pandemic has strained the resources of the world's healthcare systems. Most individuals with neurodevelopmental disabilities (NDDs) experience significant mental health issues and face substantial barriers in accessing appropriate supports which have been exacerbated during the pandemic. It is unknown the extent to which COVID-19 impacted the demand for and effectiveness of inpatient care for those with NDDs. The impact of COVID-19 on the number of admissions of youth with NDDs to pediatric inpatient psychiatry units, as well as their functioning and length of stay during the first two years of the pandemic was analyzed using Bayesian structural time series models. Admission data of youth with NDDs from four pediatric inpatient units in Alberta, Canada (n = 2144) was examined. Inpatient admissions of youth with NDDs significantly increased following the onset of the pandemic. Compared to the period prior to the pandemic, patients with NDDs had significantly worse overall functioning and received fewer days of treatment. These findings highlight the need for increased resources to support the mental health needs of this vulnerable population and are consistent with other studies in the general population examining the utilization of inpatient psychiatric units during the pandemic.

Mental health challenges faced by autistic people

Mental health challenges impede the well-being of autistic people. This Review outlines contributing neurodevelopmental and physical health conditions, rates and developmental trajectories of mental health challenges experienced by autistic people, as well as unique clinical presentations. A framework is proposed to consider four contributing themes to aid personalized formulation: social-contextual determinants, adverse life experiences, autistic cognitive features, and shared genetic and early environmental predispositions. Current evidence-based and clinical-knowledge-informed intervention guidance and ongoing development of support are highlighted for specific mental health areas. Tailored mental health support for autistic people should be neurodivergence-informed, which is fundamentally humanistic and compatible with the prevailing bio-psycho-social frameworks. The personalized formulation should be holistic, considering physical health and transdiagnostic neurodevelopmental factors, intellectual and communication abilities, and contextual-experiential determinants and their interplay with autistic cognition and biology, alongside resilience. Supporting family well-being is integral. Mutual empathic understanding is fundamental to creating societies in which people across neurotypes are all empowered to thrive.

Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada

IMPORTANCE

Reasons for elevated suicide risks among autistic people are unclear, with insufficient population-based research on sex-specific patterns to inform tailored prevention and intervention.

OBJECTIVES

To examine sex-stratified rates of self-harm events and suicide death among autistic individuals compared with nonautistic individuals, as well as the associated sociodemographic and clinical risk factors.

DESIGN, SETTING, AND PARTICIPANTS

This population-based matched-cohort study using linked health administrative databases in Ontario, Canada included all individuals with physician-recorded autism diagnoses from April 1, 1988, to March 31, 2018, each matched on age and sex to 4 nonautistic individuals from the general population. Self-harm events resulting in emergency health care from April 1, 2005, to December 31, 2020, were examined for one cohort, and death by suicide and other causes from April 1, 1993, to December 31, 2018, were examined for another cohort. Statistical analyses were conducted between October 2021 and June 2023.

EXPOSURE

Physician-recorded autism diagnoses from 1988 to 2018 from health administrative databases.

MAIN OUTCOMES AND MEASURES

Autistic and nonautistic individuals who were sex stratified a priori were compared using Andersen-Gill recurrent event models on self-harm events, and cause-specific competing risk models on death by suicide or other causes. Neighborhood-level income and rurality indices, and individual-level broad diagnostic categories of intellectual disabilities, mood and anxiety disorders, schizophrenia spectrum disorders, substance use disorders, and personality disorders were covariates.

RESULTS

For self-harm events (cohort, 379 630 individuals; median age at maximum follow-up, 20 years [IQR, 15-28 years]; median age of first autism diagnosis claim for autistic individuals, 9 years [IQR, 4-15 years]; 19 800 autistic females, 56 126 autistic males 79 200 nonautistic females, and 224 504 nonautistic males), among both sexes, autism diagnoses had independent associations with self-harm events (females: relative rate, 1.83; 95% CI, 1.61-2.08; males: relative rate, 1.47; 95% CI, 1.28-1.69) after accounting for income, rurality, intellectual disabilities, and psychiatric diagnoses. For suicide death (cohort, 334 690 individuals; median age at maximum follow-up, 19 years [IQR, 14-27 years]; median age of first autism diagnosis claim for autistic individuals, 10 years [IQR, 5-16 years]; 17 982 autistic females, 48 956 autistic males, 71 928 nonautistic females, 195 824 nonautistic males), there was a significantly higher crude hazard ratio among autistic females (1.98; 95% CI, 1.11-3.56) and a nonsignificantly higher crude hazard ratio among autistic males (1.34; 95% CI, 0.99-1.82); the increased risks were associated with psychiatric diagnoses.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that autistic individuals experienced increased risks of self-harm events and suicide death. Psychiatric diagnoses were significantly associated with the increased risks among both sexes, especially for suicide death, and in partially sex-unique ways. Autism-tailored and autism-informed clinical and social support to reduce suicide risks should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses.

A systematic review and meta-analysis of suicidality in autistic and possibly autistic people without co-occurring intellectual disability

BACKGROUND

Suicidality is highly prevalent in autistic people without co-occurring intellectual disabilities, and high autistic traits are found in adults who have attempted suicide. However, prevalence rates for both autistic and possibly autistic people have not been synthesised meta-analytically.

AIMS

To (1) calculate pooled prevalence estimates of suicidality in autistic people and possibly autistic people without co-occurring intellectual disability; (2) evaluate the influence of participant and study level characteristics on heterogeneity; and (3) determine the quality of evidence.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PsycINFO, Embase, MEDLINE and Web of Science were systematically searched from 1992 to January 25, 2022. Empirical quantitative studies reporting prevalence of suicidal ideation, suicide plans, or suicide attempts and behaviours were considered for inclusion. Random effects models were used to estimate pooled prevalence of each suicidality outcome with 95% confidence intervals. Heterogeneity was explored using sensitivity and moderator analyses.

RESULTS

Data from 48,186 autistic and possibly autistic participants in 36 primary studies were meta-analysed. Pooled prevalence of suicidal ideation was 34.2% (95% CI 27.9-40.5), suicide plans 21.9% (13.4-30.4), and suicidal attempts and behaviours 24.3% (18.9-29.6). High levels of heterogeneity (I² > 75) were observed in all three analyses. Estimates did not differ between autistic or possibly autistic samples. Geographical location (p = 0.005), transgender or gender non-conforming samples (p < 0.001) and type of report (p < 0.001) significantly moderated suicidal ideation, whereas age group (p = 0.001) and measure of suicidality (p = 0.001) significantly moderated suicide plans. There was a significant association between the proportion of male participants and prevalence of suicide plans, with a decrease in the proportion of males for every unit change of suicide plan prevalence (p = 0.013). No variables were found to moderate estimates of suicide attempts and behaviours.

CONCLUSIONS

The results confirm suicidality is highly prevalent in both autistic and possibly autistic people without co-occurring intellectual disability and highlights potential moderators. Possibly autistic individuals require more attention in clinical and research considerations going forward to further understand and prevent suicide in both groups.

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.

Community-guided measurement-based care for autistic youth and adults receiving psychotherapy: A conceptual overview and pilot implementation study of MBC-AUT

LAY ABSTRACT

Autistic youth and adults are more likely to experience psychiatric symptoms (e.g. depression, anxiety) and to use psychiatric services than non-autistic people, yet research on evidence-based approaches to enhance psychiatric care for autistic people is limited. Measurement-based care is an evidence-based approach to psychotherapy that improves outcomes for clients, clinicians, and organizations by routinely administering and evaluating measures to clients. Despite this, research on measurement-based care systems for autistic clients is sparse. To address this gap, we developed an autism-adapted measurement-based care (MBC-AUT) system for and with autistic people and pilot tested the system in an outpatient psychiatry clinic to investigate the preliminary feasibility, acceptability, benefits, and barriers to this system for clients and clinicians. Findings suggested that the MBC-AUT system was a feasible and acceptable system for the first 18 autistic youth, their caregivers, and autistic adults to use the system. In semi-structured interviews, clients and clinicians discussed the benefits of the MBC-AUT system to various therapeutic processes, as well as several important barriers to the use of the system. We offer potential solutions to address these barriers and to reduce client and clinician burden, and propose future directions for this line of research to increase access to more autistic people. As autistic clients continue to seek psychological services amid social landscapes of increasing complexity (e.g. COVID-19 pandemic), efforts to enhance the delivery of psychotherapy for this population are critical.

Autism Spectrum Disorder: A Review

IMPORTANCE

Autism spectrum disorder (ASD), characterized by deficits in social communication and the presence of restricted, repetitive behaviors or interests, is a neurodevelopmental disorder affecting approximately 2.3% children aged 8 years in the US and approximately 2.2% of adults. This review summarizes evidence on the diagnosis and treatment of ASD.

OBSERVATIONS

The estimated prevalence of ASD has been increasing in the US, from 1.1% in 2008 to 2.3% in 2018, which is likely associated with changes in diagnostic criteria, improved performance of screening and diagnostic tools, and increased public awareness. No biomarkers specific to the diagnosis of ASD have been identified. Common early signs and symptoms of ASD in a child's first 2 years of life include no response to name when called, no or limited use of gestures in communication, and lack of imaginative play. The criterion standard for the diagnosis of ASD is a comprehensive evaluation with a multidisciplinary team of clinicians and is based on semistructured direct observation of the child's behavior and semistructured caregiver interview focused on the individual's development and behaviors using standardized measures, such as the Autism Diagnostic Observation Schedule-Second Edition and the Autism Diagnostic Interview. These diagnostic measures have sensitivity of 91% and 80% and specificity of 76% and 72%, respectively. Compared with people without ASD, individuals with ASD have higher rates of depression (20% vs 7%), anxiety (11% vs 5%), sleep difficulties (13% vs 5%), and epilepsy (21% with co-occurring intellectual disability vs 0.8%). Intensive behavioral interventions, such as the Early Start Denver Model, are beneficial in children 5 years or younger for improvement in language, play, and social communication (small to medium effect size based on standardized mean difference). Pharmacotherapy is indicated for co-occurring psychiatric conditions, such as emotion dysregulation or attention-deficit/hyperactivity disorder. Risperidone and aripiprazole can improve irritability and aggression (standardized mean difference of 1.1, consistent with a large effect size) compared with placebo. Psychostimulants are effective for attention-deficit/hyperactivity disorder (standardized mean difference of 0.6, consistent with a moderate effect size) compared with placebo. These medications are associated with adverse effects including, most commonly, changes in appetite, weight, and sleep.

CONCLUSIONS AND RELEVANCE

ASD affects approximately 2.3% of children aged 8 years and approximately 2.2% of adults in the US. First-line therapy consists of behavioral interventions, while co-occurring psychiatric conditions, such as anxiety or aggression, may be treated with specific behavioral therapy or medication.

Co-occurrence patterns of adverse childhood experiences and their associations with non-suicidal self-injury and suicidal behaviors and gender difference among middle school students: A three-city survey in China

BACKGROUND

Previous research has found increasing evidence of adverse childhood experiences (ACEs) leading to non-suicidal self-injury (NSSI) and suicidal behaviors. Most studies have focused on a certain type or timing of ACEs or the patterns of multiple types; however, few of them have examined the patterns of ACEs combined types and timing and the gender differences in the association between ACEs and self-harming behaviors.

METHODS

A cross-sectional survey was conducted in three Chinese cities from November 2020 to May 2021. We asked 16,853 middle school students to anonymously complete a questionnaire to provide the details of their own ACEs and NSSI or suicidal behaviors.

RESULTS

Latent class analysis identified four classes: high ACEs (10 %), high abuse/neglect (20.3 %), moderate ACEs (26.7 %) and low ACEs (43 %). Logistic regression models demonstrated that students in the high ACEs, high abuse/neglect and moderate ACEs subgroups were more likely to engage in NSSI and suicidal behaviors than students with low ACEs. Compared with boys, girls had a higher probability of engaging in NSSI and suicidal behaviors when exposed to the same level of ACEs.

CONCLUSION

Co-occurrence of ACEs is associated with high risk of NSSI and suicidal behaviors. Our findings recognized the most dangerous patterns and latent class membership, which supply the evidence for policy makers to adopt preventive measures to protect high-risk individuals. Strategies to relieve the impact of ACEs, especially on girls, need to be considered comprehensively.

LIMITATIONS

The study was limited by cross-sectional design, as causality could not be confirmed. In addition, because our survey was retrospective, potential recall bias can not be ignored.

Suicidality and epilepsy: A systematic review and meta-analysis

Background

We aimed to evaluate the association between epilepsy and suicidality, including suicidal ideation, attempts and completed suicide.

Methods

We systematically searched PubMed, Embase, Cochrane Online Library, and Clinicaltrials.gov from 1946 to June 21, 2021 and assessed the quality of the studies using the Newcastle-Ottawa Scale. We calculated the pooled OR and the crude rate for suicidal ideation, suicide attempts and completed suicide in patients with epilepsy (PWE).

Results

We screened 2,786 studies and included 88 articles with 1,178,401 PWE and 6,900,657 participants as controls. Search terms included epilepsy and suicide. The pooled rates of suicidal ideation, suicide attempts and completed suicide in PWE were 19.73% (95% CI: 17.00-22.62%), 5.96% (95% CI: 4.82-7.20%), and 0.24% (95% CI: 0.11-0.42%), respectively. Compared to the control group, PWE were at a significantly higher risk of total suicidality (pooled OR, 2.60; 95%: 2.13-3.18), including suicidal ideation (pooled OR, 2.70; 95% CI, 2.21-3.30), suicide attempts (pooled OR, 2.74; 95% CI, 2.08-3.61) and completed suicide (pooled OR, 2.36; 95% CI, 1.45-3.83). Subgroup analyses showed significant differences in the subgroups of the measurement of suicidality.

Conclusion

The rate of suicidal ideation, suicide attempts and completed suicide in PWE were about 19.73, 5.96, and 0.24%. And there was an increased risk of suicidality in PWE especially temporal lobe epilepsy and drug-resistant epilepsy. Clinicians need to be aware of this risk in PWE with early identification and prevention at the time of diagnosis.Protocol Registration: PROSPERO CRD42021278220.

A Scoping Review of Autism and the Way It Changes the Presentation of Suicidal Thoughts and Behavior Compared to the General Population

Autism spectrum conditions are a group of neurodevelopmental conditions that carries an array of co-occurring diagnoses, including a heightened risk of suicide attempts and suicide. This scoping review examined primary research focusing on autism and suicidality, to understand what is currently known on the topic, including how autism changes the presentation of suicidal thoughts and behavior; and to assess the suicide awareness and prevention education programs currently available for autistic people, their families, and health professionals and support workers. A comprehensive search (November 2021) across Scopus, PubMed and CINAHL identified 39 articles from 38 studies. Three themes emerged, with five subthemes. 1. The prevalence of suicidality in autistic people; 2. The presentation of suicidality in autistic people, including (a) risk of suicidality; (b) gender, age, employment and education; (c) co-occurring psychiatric conditions; (d) autism traits and social communication; (e) intellectual disability; and 3. Autism-specific approaches to suicidal thoughts, behavior and prevention. Findings were mixed, including conflicting evidence on the risk of autism and suicidality, and limited evidence of resources related to autism-specific suicide awareness or information, and education or prevention programs.