R U OK? Autism: Suicide Risk and Prevention
Written by Dr Theresa Kidd
Research in recent years has revealed suicide attempt and completion rates are 3-10 times higher amongst autistic individuals than non-autistics, across all age ranges beginning from 10 years of age (Hirvikosk, et al., 2018; Kõlves et al., 2021). In addition, suicide rates are much higher amongst autistic girls and women compared to autistic boys and men which is in contrast with suicide statistics for non-autistics. Having co-occurring mental health problems such as anxiety or depression increases the risk of suicide for autistic individuals. With extremely high rates of anxiety and depression co-occurrence in autism, there is an urgency to research risk detection and prevention of suicide for autistic individuals. This is especially true for autistic-trans people, who are at a greater risk for depression and anxiety compared to those who are transgender but non-autistic, or cisgender and autistic.
Why might suicide rates be higher?
Diagnostic overshadowing
Many autistic individuals are not accepted into mental health services because their difficulties are seen as part of their disability, leaving mental health symptoms untreated.
Presentation
Changes that may alert us that non-autistic people are not coping with life, such as poor sleep, reduced appetite, and lack of social relationships are common within autism generally and therefore cannot be relied upon as a sign of suicidality.
Access to mental health treatment
Autistic individuals may have difficulty accessing treatment that suits their cognitive profile. Despite research demonstrating that psychological treatment modified to suit the autistic person’s cognitive profile can significantly improve mental health, many clinicians do not feel competent in working with autistic people due to a lack of training in autism.
Co-occurrence
Clinicians may not be aware that there is a high co-occurrence between autism and eating disorders, and autism and gender dysphoria which may affect treatment course and therapeutic response if autism is left undetected.
Camouflaging
Many autistic individuals spend large amounts of energy to socially perform or to pass as ‘non-autistic,’ making them eight times as likely to harm themselves as those who do not camouflage. A disconnect between their ‘true self’ and their performing self can occur and low self-esteem, a lack of self-identity and increased anxiety and depression symptoms may result.
Trauma
Researchers have found that between 26-30% of autistic youth have been exposed to various trauma such as physical/ sexual abuse, accidents, disasters or witnessing a traumatic event. Other studies have found that between 44-77% of autistic children are victims of bullying compared to 2-17% of their non-autistic peers.
What can we do on a global level?
Increase recognition and understanding of autism (including more internalised presentations) in medical and allied health training.
Determine appropriate assessment of anxiety and depression symptoms, and suicide risk when they co-occur with autism. There is currently a lack of measurement tools for mental health status and suicide risk that have been validated for autistic youth or adults.
Improve coordination and communication across sectors. It seems to be assumed that if a person has a disability, then their needs will be supported by the disability sector even though the disability sector will often not resource mental health support and treatment.
Develop resources to assist allied health professionals employed in these services to educate and upskill them in autism and co-occurring mental health assessment and treatment.
Develop and implement autistic-informed service delivery such as sensory neutral spaces and a choice of communication methods, for example, in public hospitals and mental health services to make this process more inclusive of autistic needs.
Increase awareness and acceptance of autistic individuals and neurodivergence more generally within schools, universities, workplaces, and the community. For too long society has focused on how autistic individuals can change but we urgently need to focus on how non-autistics can genuinely accept and be inclusive of neurodivergence. This is likely to reduce feelings of rejection and suicide ideation for autistic people.
What can we do on an individual level?
Identify known risk factors – e.g., anxiety, depression, bullying, social challenges, ADHD and being gender-diverse.
Monitor changes in anxiety and depression levels.
Make risk assessments more visual, using concrete language and rating scales.
Check in regularly since we may not notice changes in behaviour.
Provide concrete and visual examples when formulating a safety plan.
Include parents/ supporting adults in the plan if possible and appropriate.
With many autistic individuals having difficulty in recognising and expressing how they are feeling, working on increasing interoception and reducing alexithymia may be helpful.
Modify psychological treatment to suit the individual cognitive and communication profile of the autistic person.
Accommodate for the individual’s sensory needs to reduce sensory overload. This may look like, for example, using lamps (rather than harsh, bright lighting), refraining from wearing strong perfume or allowing the person to move around freely while talking with you (rather than sitting across from you and making eye contact).
Help in building protective factors such as social connections/ friendships, a positive sense of self, sense of purpose/ mastery, sense of control and effective ways to seek help.
If there’s an autistic person in your life who you think may be struggling, you can find a neurodivergent perspective on having an R U OK? conversation with neurodivergent people in this interview with Rachel Worsley and Mathew Farmarkis of Neurodiversity Media.
References
Dickerson Mayes, S., 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
Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., & Bölte, S. Premature mortality in autism spectrum disorder. (2016). British Journal of Psychiatry, 208(3), 232-8. doi: 10.1192/bjp.bp.114.160192
Kõlves, K., Fitzgerald, C., Nordentoft, M., Wood, S.J., & Erlangsen, A. (2021) Assessment of suicidal behaviors among individuals with autism spectrum disorder in Denmark. JAMA, 4(1). doi: 10.1001/jamanetworkopen.2020.33565
Murphy, J., Prentice, F., Walsh, R., Catmur, C., Bird, G. (2020). Autism and transgender identity: Implications for depression and anxiety. Research in Autism Spectrum Disorders, 69. doi: 10.1016/j.rasd.2019.101466
South, M., Costa, A.P., & McMorris, C. (2021). Death by suicide among people with autism: Beyond Zebrafish. JAMA, 4(1). doi: 10.1001/jamanetworkopen.2020.34018