Evidence suggests increased rates of suicidality in autism spectrum disorder (ASD), but the research has rarely used comparison samples and the role of emotion dysregulation has not been considered. We compared the prevalence of parent-reported suicidality ideation and considered the role of emotion dysregulation in 330 psychiatric inpatient youth with ASD, 1169 community youth with ASD surveyed online, and 1000 youth representative of the US census. The prevalence of suicidal ideation was three and five times higher in the community and inpatient ASD samples, respectively, compared to the general US sample. In the ASD groups, greater emotion dysregulation was associated with suicidal ideation. Implications include consideration of emotion regulation as a potential mechanism and treatment target for suicidality in ASD.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Achenbach T, Rescorla LA (2001) Manual for the ASEBA school-age forms and profiles. University of Vermont Research Center for Children, Youth, and Families, Burlington, VT
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2), 217–237. https://doi.org/10.1016/j.cpr.2009.11.004.
Berthoz, S., & Hill, E. L. (2005). The validity of using self-reports to assess emotion regulation abilities in adults with autism spectrum disorder. European Psychiatry, 20, 291–298. https://doi.org/10.1016/j.eurpsy.2004.06.013.
Bird, G., & Cook, R. (2013). Mixed emotions: The contribution of alexithymia to the emotional symptoms of autism. Translational Psychiatry, 3(7), e285–e288. https://doi.org/10.1038/tp.2013.61.
Blakeley-Smith, A., Reaven, J., Ridge, K., & Hepburn, S. (2012). Parent–child agreement of anxiety symptoms in youth with autism spectrum disorders. Research in Autism Spectrum Disorders, 6(2), 707–716. https://doi.org/10.1016/j.rasd.2011.07.020.
Cai, R. Y., Richdale, A. L., Foley, K.-R. R., Trollor, J., & Uljarević, M. (2018a). Brief report: Cross-sectional interactions between expressive suppression and cognitive reappraisal and its relationship with depressive symptoms in autism spectrum disorder. Research in Autism Spectrum Disorders, 45, 1–8. https://doi.org/10.1016/j.rasd.2017.10.002.
Cai, R. Y., Richdale, A., Uljarevic, M., Dissanayake, C., & Samson, A. C. (2018b). Emotion regulation in autism spectrum disorder: Where we are and where we need to go. Autism Research, 11(7), 962–978. https://doi.org/10.1002/aur.1968.
Cassidy, S., Bradley, P., Robinson, J., Allison, C., McHugh, M., & Baron-Cohen, S. (2014). Suicidal ideation and suicide plans or attempts in adults with Asperger’s syndrome attending a specialist diagnostic clinic: A clinical cohort study. The Lancet Psychiatry, 1(2), 142–147. https://doi.org/10.1016/S2215-0366(14)70248-2.
Cassidy, S. A., Bradley, L., Bowen, E., Wigham, S., & Rodgers, J. (2018a). Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review. Autism Research, 62, 56–70. https://doi.org/10.1002/aur.1922.
Cassidy, S., Bradley, L., Shaw, R., & Baron-Cohen, S. (2018b). Risk markers for suicidality in autistic adults. Molecular Autism, 9(1), 1–14. https://doi.org/10.1186/s13229-018-0226-4.
Centers for Disease Control (2017) QuickStats: Suicide Rates for teens aged 15–19 years, by sex—United States 1975–2015. Morbidity and Mortality Weekly Report, 66(30), 816. https://doi.org/10.15585/mmwr.mm6630a6
Conner, C. M., Golt, J., Righi, G., Shaffer, R. C., Siegel, M., & Mazefsky, C. A. (in preparation). The influence of emotion dysregulation on outcomes in ASD: Comparison of inpatient ASD, community ASD, and US census-matched youth samples.
Conner, C. M., White, S. W., Beck, K. B., Golt, J., Smith, I. C., & Mazefsky, C. A. (2019). Improving emotion regulation ability in autism: The Emotional Awareness and Skills Enhancement (EASE) program. Autism, 23(5), 1273–1287. https://doi.org/10.1177/1362361318810709.
Daniels, A. M., Rosenberg, R. E., Anderson, C., Law, J. K., Marvin, A. R., & Law, P. A. (2012). Verification of parent-report of child autism spectrum disorder diagnosis to a web-based autism registry. Journal of Autism and Developmental Disorders, 42(2), 257–265. https://doi.org/10.1007/s10803-011-1236-7.
Davey, S., Halberstadt, J., Bell, E., & Collings, S. (2018). A scoping review of suicidality and alexithymia: The need to consider interoception. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2018.06.027.
Demirkaya, S. K., Tutkunkardaş, M. D., & Mukaddes, N. M. (2016). Assessment of suicidality in children and adolescents with diagnosis of high functioning autism spectrum disorder in a Turkish clinical sample. Neuropsychiatric Disease and Treatment, 12, 2921–2926. https://doi.org/10.2147/NDT.S118304.
Duerden, E. G., Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P., et al. (2012). Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(11), 2460–2470. https://doi.org/10.1007/s10803-012-1497-9.
Goodwin, M. S., Mazefsky, C. A., Ioannidis, S., Erdogmus, D., & Siegel, M. (2019). Predicting aggression to others in youth with autism using a wearable biosensor. Autism Research, 12(8), 1286–1296. https://doi.org/10.1002/aur.2151.
Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2(5), 271–299.
Gross, J. J., & Thompson, R. A. (2006). Emotion regulation: Conceptual foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–26). New York: Guilford Press.
Hatkevich, C., Penner, F., & Sharp, C. (2019). Difficulties in emotion regulation and suicide ideation and attempt in adolescent inpatients. Psychiatry Research, 271, 230–238. https://doi.org/10.1016/j.psychres.2018.11.038.
Hayes, A. F. (2015). The PROCESS macro for SPSS and SAS.
Hedley, D., Uljarević, M., Wilmot, M., Richdale, A., & Dissanayake, C. (2017). Brief report: Social support, depression and suicidal ideation in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47(11), 3669–3677. https://doi.org/10.1007/s10803-017-3274-2.
Hedley, D., Uljarević, M., Wilmot, M., Richdale, A., & Dissanayake, C. (2018). Understanding depression and thoughts of self-harm in autism: A potential mechanism involving loneliness. Research in Autism Spectrum Disorders, 46, 1–7. https://doi.org/10.1016/j.rasd.2017.11.003.
Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., & Bölte, S. (2016). Premature mortality in autism spectrum disorder. The British Journal of Psychiatry, 208(3), 232–238.
Horowitz, L. M., Thurm, A., Farmer, C., Mazefsky, C., Lanzillo, E., Bridge, J. A., et al. (2018). Talking about death or suicide: Prevalence and clinical correlates in youth with autism spectrum disorder in the psychiatric inpatient setting. Journal of Autism and Developmental Disorders, 48(11), 3702–3710. https://doi.org/10.1007/s10803-017-3180-7.
Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
Joshi, G., Wozniak, J., Fitzgerald, M., Faraone, S., Fried, R., Galdo, M., et al. (2018). High risk for severe emotional dysregulation in psychiatrically referred youth with autism spectrum disorder: A controlled study. Journal of Autism and Developmental Disorders, 48, 3101–3115. https://doi.org/10.1007/s10803-018-3542-9.
Kato, K., Mikami, K., Akama, F., Yamada, K., Maehara, M., Kimoto, K., et al. (2013). Clinical features of suicide attempts in adults with autism spectrum disorders. General Hospital Psychiatry, 35(1), 50–53. https://doi.org/10.1016/j.genhosppsych.2012.09.006.
Khor, A. S., Melvin, G. A., Reid, S. C., & Gray, K. M. (2014). Coping, daily hassles and behavior and emotional problems in adolescents with high-functioning autism/Asperger’s disorder. Journal of Autism and Developmental Disorders, 44, 593–608. https://doi.org/10.1007/s10803-013-1912-x.
Kirby, A. V. (2019). Suicide and autism spectrum disorder: Associated health conditions. In INSAR 2019 pre-meeting on mental health, Montreal.
Kirby, A. V., Bakian, A. V., Zhang, Y., Bilder, D. A., Keeshin, B. R., & Coon, H. (2019). A 20-year study of suicide death in a statewide autism population. Autism Research, 12, 658–666. https://doi.org/10.1002/aur.2076.
Kleiman, E. M., & Liu, R. T. (2013). Social support as a protective factor in suicide: Findings from two nationally representative samples. Journal of Affective Disorders, 150(2), 540–545. https://doi.org/10.1016/j.jad.2013.01.033.
Lai, J. K. Y., Rhee, E., & Nicolas, D. (2017). Suicidality in autism spectrum disorder: A commentary. Advances in Neurodevelopmental Disorders, 1(3), 190–195. https://doi.org/10.1007/s41252-017-0018-4.
Lee, H., Marvin, A. R., Watson, T., Piggot, J., Law, J. K., Law, P. A., et al. (2010). Accuracy of phenotyping of autistic children based on internet implemented parent report. American Journal of Medical Genetics, Part B: Neuropsychiatric Genetics, 153(6), 1119–1126. https://doi.org/10.1002/ajmg.b.31103.
Lerner, M. D., Calhoun, C. D., Mikami, A. Y., & De Los, R. A. (2012). Understanding parent–child social informant discrepancy in youth with high functioning autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(12), 2680–2692. https://doi.org/10.1007/s10803-012-1525-9.
Lipkin, P. H., Rybczynski, S., Ryan, T., & Wilcox, H. (2019). Screening for suicide risk in children with autism and related disabilities in a pediatric autism center. Montreal: In International meeting for autism research.
Loevaas, M. E. S., Sund, A. M., Lydersen, S., Neumer, S.-P., Martinsen, K., Holen, S., et al. (2019). Does the transdiagnostic EMOTION intervention improve emotion regulation skills in children? Journal of Child and Family Studies, 28(3), 805–813. https://doi.org/10.1007/s10826-018-01324-1.
Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. L. (2012). Autism Diagnostic Observation Schedule-2. Los Angeles: Western Psychological Services.
Maddox, B. B., Trubanova, A., & White, S. W. (2017). Untended wounds: Non-suicidal self-injury in adults with autism spectrum disorder. Autism, 21(4), 412–422. https://doi.org/10.1177/1362361316644731.
Mayes, S. D., 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. https://doi.org/10.1016/j.rasd.2012.07.009.
Mazefsky, C. A., Yu, L., & Pilkonis, P. A. (2020). Psychometric properties of the Emotion Dysregulation Inventory in a nationally representative sample of youth. Journal of Clinical Child and Adolescent Psychiatry. https://doi.org/10.1080/15374416.2019.1703710
Mazefsky, C. A., Kao, J., & Oswald, D. P. (2011). Preliminary evidence suggesting caution in the use of psychiatric self-report measures with adolescents with high-functioning autism spectrum disorders. Research in Autism Spectrum Disorders, 5(1), 164–174. https://doi.org/10.1016/j.rasd.2010.03.006.
Mazefsky, C. A., Borue, X., Day, T. N., & Minshew, N. J. (2014). Emotion regulation patterns in adolescents with high functioning autism spectrum disorder: Comparison to typically developing adolescents and association with psychiatric symptoms. Autism Research, 7(3), 344–354. https://doi.org/10.1002/aur.1366.
Mazefsky, C. A., Day, T. N., Siegel, M., White, S. W., Yu, L., & Pilkonis, P. A. (2018a). Development of the Emotion Dysregulation Inventory: A PROMIS®ing method for creating sensitive and unbiased questionnaires for autism spectrum disorder. Journal of Autism and Developmental Disorders, 48(11), 3736–3746. https://doi.org/10.1007/s10803-016-2907-1.
Mazefsky, C. A., Yu, L., White, S. W., Siegel, M., & Pilkonis, P. A. (2018b). The Emotion Dysregulation Inventory: Psychometric properties and Item Response Theory calibration in an autism spectrum disorder sample. Autism Research, 11(6), 928–941. https://doi.org/10.1002/aur.1947.
McCauley, E., Gudmundsen, G., Scholredt, K., Martell, C., Rhew, I., Hubley, S., et al. (2016). The adolescent behavioral activation program: Adapting behavioral activation as a treatment for depression in adolescence. Journal of Clinical Child and Adolescent Psychology, 45(3), 291–304. https://doi.org/10.1080/15374416.2014.979933.
McMakin, D. L., Siegle, G. J., & Shirk, S. R. (2011). Positive Affect Stimulation and Sustainment (PASS) module for depressed mood: A preliminary investigation of treatment-related effects. Cognitive Therapy and Research, 35(3), 217–226. https://doi.org/10.1007/s10608-010-9311-5.
Miller, A. B., McLaughlin, K. A., Busso, D. S., Brueck, S., Peverill, M., & Sheridan, M. A. (2018). Neural correlates of emotion regulation and adolescent suicidal ideation. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 3(2), 125–132. https://doi.org/10.1016/j.bpsc.
Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. Journal of Consulting and Clinical Psychology, 76(1), 28–38. https://doi.org/10.1037/0022-006X.76.1.28.
Nock, M. K., Hwang, I., Sampson, N. A., & Kessler, R. C. (2010). Mental disorders, comorbidity and suicidal behavior: Results from the National Comorbidity Survey Replication. Molecular Psychiatry, 15(8), 868–876. https://doi.org/10.1038/mp.2009.29.
Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., et al. (2013). Prevalence, correlates and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). JAMA Psychiatry, 70(3), 1–24. https://doi.org/10.1001/2013.jamapsychiatry.55.
O’Connor, R. C. (2011). The integrated motivational–volitional model of suicidal behavior. Crisis, 32(6), 295–298. https://doi.org/10.1027/0227-5910/a000120.
O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. The Lancet Psychiatry, 1(1), 73–85. https://doi.org/10.1016/S2215-0366(14)70222-6.
Raja, M., Azzoni, A., & Frustaci, A. (2011). Autism spectrum disorders and suicidality. Clinical Practice and Epidemiology in Mental Health, 7(1), 97–105. https://doi.org/10.2174/1745017901107010097.
Richa, S., Fahed, M., Khoury, E., & Mishara, B. (2014). Suicide in autism spectrum disorders. Archives of Suicide Research, 18(4), 327–339. https://doi.org/10.1080/13811118.2013.824834.
Rutter, M., Bailey, A., & Lord, C. (2003). The Social Communication Questionnaire. Los Angeles: Western Psychological Services.
Samson, A. C., & Antonelli, Y. (2013). Humor as character strength and its relation to life satisfaction and happiness in Autism spectrum disorders. Humor, 26(3), 477–491. https://doi.org/10.1515/humor-2013-0031.
Samson, A. C., Huber, O., & Ruch, W. (2013). Seven decades after Hans Asperger’s observations: A comprehensive study of humor in individuals with Autism Spectrum Disorders. Humor, 26(3), 441–460. https://doi.org/10.1515/humor-2013-0026.
Samson, A. C., Hardan, A. Y., Lee, I. A., Phillips, J. M., & Gross, J. J. (2015). Maladaptive behavior in autism spectrum disorder: The role of emotion experience and emotion regulation. Journal of Autism and Developmental Disorders, 45(11), 3424–3432. https://doi.org/10.1007/s10803-015-2388-7.
Segers, M., & Rawana, J. (2014). What do we know about suicidality in autism spectrum disorders? A systematic review. Autism Research, 7(4), 507–521. https://doi.org/10.1002/aur.1375.
Shaffer, R. C., Wink, L. K., Ruberg, J., Pittenger, A., Adams, R., Sorter, M., et al. (2019). Emotion regulation intensive outpatient programming: Development, feasibility, and acceptability. Journal of Autism and Developmental Disorders, 49(2), 495–508. https://doi.org/10.1007/s10803-018-3727-2.
Siegel, M., Doyle, K., Chemelski, B., Payne, D., Ellsworth, B., Harmon, J., et al. (2012). Specialized inpatient psychiatry units for children with autism and developmental disorders: A United States survey. Journal of Autism and Developmental Disorders, 42(9), 1863–1869. https://doi.org/10.1007/s10803-011-1426-3.
Siegel, M., Smith, K. A., Mazefsky, C., Gabriels, R. L., Erickson, C., Kaplan, D., et al. (2015). The autism inpatient collection: Methods and preliminary sample description. Molecular Autism, 6(61), 1–10. https://doi.org/10.1186/s13229-015-0054-8.
Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan, K., Holland, K. M., et al. (2018). Vital signs: Trends in state suicide rates—United States, 1999–2016 and circumstances contributing to suicide—27 States, 2015. Morbidity and Mortality Weekly Report, 67(22), 617–624. https://doi.org/10.15585/mmwr.mm6722a1.
Storch, E. A., Sulkowski, M. L., Nadeau, J., Lewin, A. B., Arnold, E. B., Mutch, P. J., et al. (2013). The phenomenology and clinical correlates of suicidal thoughts and behaviors in youth with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(10), 2450–2459. https://doi.org/10.1007/s10803-013-1795-x.
Stratis, E. A., & Lecavalier, L. (2017). Predictors of parent–teacher agreement in youth with autism spectrum disorder and their typically developing siblings. Journal of Autism and Developmental Disorders, 47(8), 2575–2585. https://doi.org/10.1007/s10803-017-3173-6.
Van Eck, K., Ballard, E., Hart, S., Newcomer, A., Musci, R., & Flory, K. (2015). ADHD and suicidal ideation: The roles of emotion regulation and depressive symptoms among college students. Journal of Attention Disorders, 19(8), 703–714. https://doi.org/10.1177/1087054713518238.
Volkaert, B., Wante, L., Vervoort, L., & Braet, C. (2018). ‘Boost Camp’, a universal school-based transdiagnostic prevention program targeting adolescent emotion regulation; evaluating the effectiveness by a clustered RCT: A protocol paper. BMC Public Health, 18(1), 1–14.
Weiner, L., Flin, A., Causin, J., Weibel, S., & Bertschy, G. (2019). A case study of suicidality presenting as a restricted interest in autism spectrum disorder. BMC Psychiatry, 19(126), 1–5. https://doi.org/10.1186/s12888-019-2122-7.
Weiss, J. A. (2014). Transdiagnostic case conceptualization of emotional problems in youth with ASD: An emotion regulation approach. Clinical Psychology: Science and Practice, 21, 331–350.
Weiss, J. A., Thomson, K., Burnham Riosa, P., Albaum, C., Chan, V., Maughan, A., et al. (2018). A randomized waitlist-controlled trial of cognitive behavior therapy to improve emotion regulation in children with autism. Journal of Child Psychology and Psychiatry, 59(11), 1180–1191. https://doi.org/10.1111/jcpp.12915.
Williams, J. M. G., & Williams, M. (1997). Cry of pain: Understanding suicide and self-harm. New York: Penguin Group.
This study was supported with funding from NICHD R01 HD079512 (CM), the Ritvo-Slifka Award for Innovation in Autism Research (CM), Simons Foundation Autism Research Initiative and the Nancy Lurie Marks Family Foundation (SFARI #296318, M.S.). IAN is a Partnership Project of the Kennedy Krieger Institute and the Simons Foundation. IAN is also partially funded through a Patient-Centered Outcomes Research Institute (PCORI) Award for Development of the National Patient-Centered Clinical Research Network, known as PCORnet.
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the Ethical Standards of the University of Pittsburgh Institutional Review Board and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Conner, C.M., Golt, J., Righi, G. et al. A Comparative Study of Suicidality and Its Association with Emotion Regulation Impairment in Large ASD and US Census-Matched Samples. J Autism Dev Disord 50, 3545–3560 (2020). https://doi.org/10.1007/s10803-020-04370-1
- Emotion regulation