This article was downloaded by: [Selcuk Universitesi] On: 27 January 2015, At: 20:55 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Archives of Suicide Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usui20

Suicide in Autism Spectrum Disorders a

a

a

Sami Richa , Mario Fahed , Elias Khoury & Brian Mishara a

b

Hôtel-dieu de France , Beirut , Lebanon

b

Université du Québec, Montréal, CRISE-UQAM , Montréal , Québec , Canada Accepted author version posted online: 08 Apr 2014.Published online: 07 Nov 2014.

Click for updates To cite this article: Sami Richa , Mario Fahed , Elias Khoury & Brian Mishara (2014) Suicide in Autism Spectrum Disorders, Archives of Suicide Research, 18:4, 327-339, DOI: 10.1080/13811118.2013.824834 To link to this article: http://dx.doi.org/10.1080/13811118.2013.824834

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Downloaded by [Selcuk Universitesi] at 20:55 27 January 2015

Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions

Archives of Suicide Research, 18:327–339, 2014 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2013.824834

Suicide in Autism Spectrum Disorders

Downloaded by [Selcuk Universitesi] at 20:55 27 January 2015

Sami Richa, Mario Fahed, Elias Khoury, and Brian Mishara This review focuses on suicide in patients with Autism Spectrum Disorders (ASD) as well as risk factors and comorbidities of persons with ASD who have attempted suicide. Research was conducted by searching PubMed and Psychinfo for articles. Suicide in ASD is largely understudied. Although suicide is common in clinical samples, we have little knowledge of suicide in persons with ASD in the general population. Comorbidity, particularly with depression and other affective disorders or schizoid disorders and psychotic symptoms, is often reported, so it is difficult to determine if suicidality is associated with ASD or the comorbid disorder. Clinical samples suggest that suicide occurs more frequently in high functioning autism. Physical and sexual abuse, bullying, and changes in routine are precipitating events associated with suicide risk. Persons with ASD present risk factors inherent to their diagnosis (deficit in expression of feelings and thoughts), along with risk factors pertaining to the general population (abuse, depression, anxiety, etc.). The inability of persons with Pervasive Developmental Disorder (PDD) to express emotions and thoughts makes the diagnosis of suicidal ideation difficult and demands important adjustments to traditional psychotherapeutic interventions. More research is needed to determine the incidence of suicidal behaviors in persons with ASD, to identify risk and protective factors, as well as to assess the effectiveness of prevention strategies and interventions. Keywords Asperger, autism, Autism Spectrum Disorders, Pervasive Developmental Disorder, suicide, suicide attempts

INTRODUCTION

2013). This increase is thought to be primarily associated with a considerable broadening of the diagnostic concept along with increased public awareness of childhood psychiatric disorders. Nonetheless, a true rise in prevalence, due to an unidentified environmental factor, cannot be ruled out. Howlin, Karpf, and Turk (2005), in a review of 35 studies examining the outcome of ASD patients, concluded that ASD is often reported as a ‘‘frequent cause of death.’’ However, there are no population studies in which the actual proportion of suicide deaths has been determined. All published investigations involve studies of people with ASD who are undergoing

Autism Spectrum Disorders (ASD) consists of a range of disorders, including the milder Asperger Syndrome (AS), Pervasive Developmental Disorder (PDD), and Autism. They are generally characterized by communication deficits, social difficulties, and the presence of repetitive behaviors, such as repeating words or actions and obsessively following routines or schedules. The prevalence of autism spectrum disorders has increased in recent times (Maughan, Iervolino, & Collishaw, 2005) and has reached over one percent of the general population (Fernell, Eriksson, & Gillberg,

327

Downloaded by [Selcuk Universitesi] at 20:55 27 January 2015

Suicide in Autism Spectrum Disorders

evaluations or receiving treatment. There exists very little on suicidal behavior in non-clinical populations of people with ASD. This population poses unique challenges for suicide prevention since a characteristic of ASD is having difficulties in expressing feelings and communicating with others. Thus, it is challenging to diagnose depression and identify suicidal intentions. This article reviews empirical investigations of the relationship between ASD and suicidal behaviors (completed suicides, attempts, and suicidal ideation), factors associated with suicide and ASD, and challenges for interventions and treatment of suicidal behaviors in persons with ASD. We conclude with recommendations for practitioners and challenges for future research. MATERIALS AND METHODS

We conducted a search in PubMed, Psychinfo, Embase, and Medline for articles in English with the keywords: ‘‘autism or Asperger or pervasive developmental disorder or PDD and suicide. ’’ Only 26 publications involved empirical investigations on the topic, 12 of which were actual studies and reviews on suicide in the PDD spectrum (featured in Table 1). These articles included small numbers of participants; non-randomized sampling; and data on the validity and reliability of measures were rarely reported. In addition to the empirical investigations, we include in this review several case studies and articles commenting on suicide and ASD (14 publications). Relevance to the topic was the only inclusion criteria taken into account, considering the rarity of articles pertaining to the subject. RESULTS AND DISCUSSION Suicide Mortality and Morbidity

A prospective longitudinal communitybased study showed a significantly higher

328

mortality rate in individuals with PDD, especially in females, and the authors state that the main causes of mortality included medical disorders (e.g., epilepsy) and accidents. However, this study did not take into consideration mortality from suicide (Gillberg, Billstedt, Sundh et al., 2010). A Danish study of a clinical cohort of 341 individuals with PDD diagnoses who were followed over 45 years found that their overall mortality rate was about double the rate for the general population. However, only 2 of the 26 deaths during this study were classified as suicides, one by taking medication and another by jumping from a tower bloc (Mouridsen, BrønnumHansen, Rich et al. 2008). This study confirmed earlier results on the same cohort (Isager, Mouridsen, & Rich, 1999), that found comparable suicide rates in persons with PDD to the general population, though it is important to note that the diagnostic criteria for ASD has evolved since then. A retrospective study of the medical records of a clinical sample of 235 children and adolescents found that those with a diagnosis of Autism were less likely to have engaged in suicidal behavior than youths with other diagnoses (Hardan & Sahl, 1999). A study of 42 adults with AS diagnoses living in the community found that 40% of subjects had considered committing suicide at some time in the past, and 15% of respondents reported that they had made at least one attempt to kill themselves (Balfe & Tantam, 2010). No comparison data was provided to frame these findings. Shtayermman (2007) estimated the extent of suicidal ideation in a small (N ¼ 10) sample in which parents reported on symptoms of an adolescent or young adult with AS using standardized measures. They found that 50% of the sample reported clinically significant levels of suicidal ideation and that there was a significant negative correlation between level of suicidal ideation and severity of AS. Because of the small sample size these data must be only

VOLUME 18  NUMBER 4  2014

ARCHIVES OF SUICIDE RESEARCH

329

Mortality and causes of death in pervasive developmental disorders. (1993)

Mortality and causes of death in autism spectrum disorders. An update. (2005)

Study

341 Age range: 2–17

N ¼ 341 Age range: 2–17

Mouridsen, BrønnumHansen, Rich, & Isager, 2008.

Isager, Mouridsen & Bente, 1999.

Population

Authors

TABLE 1. Studies on PDD Spectrum and Suicide

Study design: Cohort Sampling: Inpatients at the University Clinics of Child Psychiatry of Copenhagen and Aarhus during the 25 year period 1960–84. Instruments: ICD-9 Criteria

Study design: Cohort Sampling: Inpatients at the University Clinics of Child Psychiatry of Copenhagen and Aarhus during the 25 year period 1960–84. Instruments: ICD-9 Criteria

Study characteristics 1. Mortality risk among those with ASD was nearly twice that of the general population. SMR was 1.93 (CI 1.26–2.82) 2. The SMR was particularly high in females. SMR ¼ 4.01; CI (1.73–7.90) 3. No increase in mortality risk since first study in 1993. 4. Eight of the 26 deaths were associated with epilepsy and 4 died from epilepsy. 5. Two of the 26 deaths were classified as suicides. The annual mortality rate was 1.6 per 1000 per year. Mortality was related to intelligence in a U-shaped fashion, with both severe retardation and normal intelligence being associated with a relatively high risk of death.

Results

Downloaded by [Selcuk Universitesi] at 20:55 27 January 2015

(Continued )

The need to be involved with autistic people up to middle and probably even old age.

Future staff education should focus on better managing of the complex relationships between ASD and physical illness to prevent avoidable deaths.

Recommendations

330

VOLUME 18  NUMBER 4  2014

A descriptive social and health profile of a community sample of adults and adolescents with

Suicidal behavior in children and adolescents with developmental disorders.

Study

Authors

Balfe & Tantam, 2010.

Hardan & Sahl, 1999.

TABLE 1. Continued

45 out of 68 initially recruited actually had Asperger’s Age range: 13þ

233 Age Range: 3–19

Population Study design: Cohort Sampling: The program offers an after school partial hospitalization program, a summer intensive treatment program, a school-based partial program, a 24-bed inpatient unit, and an outpatient clinic. The medical charts of all individuals who entered the program over a 12-month period were reviewed. Instruments: Diagnoses were based on DSM-III-R criteria. The IQ was measured by a developmental psychologist using either the WISC-R or the Stanford-Binet. Study design: Cross-sectional Sampling: Letters to headmasters, general practitioners, neurologists, pediatricians and psychiatrists Posters Articles in newspapers.

Study characteristics

Further, and larger, community studies are needed to replicate the findings of this study.

Prospective studies are needed to further evaluate suicidality in individuals with PDD.

1. 20% reported suicidal ideations 2. Suicidality was more often encountered in individuals diagnosed with oppositional defiant disorder, depressive disorders, and post-traumatic stress disorder, and less often in the autistic and the severely= profoundly mentally retarded groups.

1. Majority of respondents were socially isolated and a large minority had been sexually or financially exploited. Almost all respondents had been bullied.

Recommendations

Results

Downloaded by [Selcuk Universitesi] at 20:55 27 January 2015

ARCHIVES OF SUICIDE RESEARCH

331

High rates of psychiatric co-morbidity in individuals with Asperger’s disorder.

An exploratory study of suicidal ideation and comorbid disorders in adolescents and young adults with Asperger’s syndrome.

Asperger syndrome.

Mukaddes & Fateh, 2010.

Shtayermman, 2007.

37 Age range: 6–20 years

10

Study design: Cross-sectional Sampling: Individuals referred to private psychiatry clinic from December 2002 to February 2007. Inclusion criteria were: (a) diagnosis of Asperger’s

Study design: Cross sectional Instruments: Customized questionnaire.

Instruments: ADI-R interviews with parents, and WASI [13] IQ assessments with Asperger patients. Customized questionnaire.

2. Anxiety or depression were common. 30% regularly became violent and hit other people. 3. 15% had attempted suicide. Differentiating characteristics were not mentioned. 1. 50% clinically significant levels of suicidal ideation, 20% met criteria for a diagnosis of Major Depressive Disorder and 30% met criteria for Generalized Anxiety Disorder. 2. Severity of AS symptomatology was negatively correlated with level of suicidal ideation. R ¼ 0.88, p ¼ 0.01. 1. 94% had at least one additional psychiatric disorder. 2. Anxiety disorders (54%), disruptive behavioral disorders (48%), and mood disorders (37%).

Downloaded by [Selcuk Universitesi] at 20:55 27 January 2015

(Continued )

The need for detailed assessment of additional psychiatric disorders in this population.

Bigger studies were needed.

332

VOLUME 18  NUMBER 4  2014

26

94 (consecutive sampling of patients who attempted

Mikami, Inomata, Hayakawa et al., 2009.

Frequency and clinical features of pervasive developmental

Population

Raja, Azzoni, and Frustaci, 2011.

Authors

Autism spectrum disorders and suicidality.

Study

TABLE 1. Continued Results

7.7% of patients committed suicide. 30.8% presented suicidal ideation. Most patients with suicidal behavior or ideation presented psychotic symptoms. (exact number not mentioned).

1. 12.8% were diagnosed with PDD 2. Lack of social support appear to be the most

Study characteristics disorder according to DSM-IV criteria; (b) Full IQ score ¼ 89 on WISC-R. Instruments: Standard psychiatric interview. The Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (K-SADS) Wechsler Intelligence Scale for Children (WISC-R). Study design: Cross-sectional Sampling: Individuals admitted to psychiatric intensive care unit of a general hospital. Instruments: Standard psychiatric interview based on the DSM-IV-TR criteria.

Study design: Cross-sectional Sampling: Consecutive sample out of 960 hospitalized for suicidal

Downloaded by [Selcuk Universitesi] at 20:55 27 January 2015

A high index of suspicion is warranted in evaluating suicidal risk in patients affected by ASDs, whatever is their age, psychiatric comorbidity, and setting of visit. This study indicates that PDD should always be a consideration when

Recommendations

ARCHIVES OF SUICIDE RESEARCH

333

The prevalence and correlates of abuse among children with autism served in comprehensive communitybased mental health settings.

disorder in adolescent suicide attempts.

Mandell, Walrath, Manteuffel et al., 2005.

156

self- mutilation) Age range:

Suicide in autism spectrum disorders.

This review focuses on suicide in patients with Autism Spectrum Disorders (ASD) as well as risk factors and comorbidities of persons with ASD who have...
144KB Sizes 0 Downloads 0 Views