Suicidality and Self-Injury in High-Functioning Adolescents with Autism Spectrum Disorder

Background: Recent studies have explored possible triggers and correlates of youth suicidality and non-suicidal self-injury (NSSI), but a specific focus on adolescents with Autism Spectrum Disorder (ASD) has been largely neglected.  It may be assumed that suicidal ideation and attempts are uncommon in individuals with ASD, relative to typically developing individuals (Mandell et al., 2005), and NSSI may be characterized as a type of restricted and repetitive self-injury often associated with ASD (Love et al., 2009).

Objectives: The purpose of this study was to investigate the prevalence and correlates of suicidality and NSSI in a sample of clinically referred adolescents with ASD and comorbid anxiety.  A related purpose was to qualitatively explore the adolescents’ accounts of their suicidality and self-harm behaviors.

Methods: Data for the present study were drawn from a sample of thirty adolescents (12-17 years old) who participated in an experimental trial of a cognitive-behavioral treatment program.  All participants had a confirmed ASD diagnosis, based on the ADOS (Lord et al., 2002) and ADI-R (Lord et al., 1994), met diagnostic criteria for at least one anxiety disorder, and were cognitively higher functioning (i.e., IQ > 70).  Data on suicidality and NSSI were collected from clinical interviews with the adolescent and parent, individual therapy session notes, and clinical case summaries.  All participating adolescents and parents completed the Short Mood and Feelings Questionnaire (SMFQ; Angold et al., 1995), a measure of adolescent depression symptoms.  Parents also completed the Adolescent Symptom Inventory-4 (ASI-4; Gadow & Sprafkin, 1998).

Results: Suicidal ideation and NSSI were fairly common in this sample.  Prior to treatment, 12 adolescents (40% of sample) endorsed suicidality and/or self-harm within the previous two years, and 5 (17% of sample) demonstrated suicidality and/or self-harm during the treatment program.  None of these behaivors were determined to be a function of the treatment program.  Participants who reported suicidality and/or NSSI at baseline endorsed significantly more depressive symptoms on the SMFQ than teens without suicidality and/or NSSI, t(28) = 2.591, p < .05.  The same pattern held for the parent-reported SMFQ, t(28) = 2.238, p < .05, and the ASI Dysthmic Disorder Symptom Severity scale, t(28) = 2.295, p < .05.  The adolescents with NSSI did not differ from those without NSSI on their ADI-R Stereotyped and Repetitive Motor Mannerisms subscale or ADOS Stereotyped Behaviors and Restricted Interests domain scores.

Conclusions: Based on these results, the incidence of suicidality and/or self-harm is quite common in higher functioning adolescents with ASD and comorbid anxiety.  Notably, the adolescents were not seeking treatment for suicidality, self-harm, or depression.  In this sample, suicidality and NSSI were associated with self-reported and parent-reported depressive symptoms.  The NSSI behaviors were not accurately captured by the repetitive and restricted behaviors domain of ASD.  Qualitative descriptions and explanations from the adolescents will also be briefly summarized, which highlight the impulsivity and peer rejection associated with many of these clinical examples.  Given the small size and clinical composition of the current sample, further study is needed with larger samples to generalize these findings.