Suicide is notoriously difficult to predict, but clinicians have a window of opportunity. “For each completed suicide, there are 25 attempts,” says Tami D. Benton, psychiatrist-in-chief at Children’s Hospital of Philadelphia. More than half of all people who die by suicide visit a healthcare provider within one month of their death.
In light of that fact, the Joint Commission, a nonprofit accreditation board for U.S. hospitals, recommended in 2016 that hospitals screen all clients for suicide risk, regardless of the reason for their visit.
Screening for depression and suicide are particularly challenging in people with autism, says Lisa Horowitz, staff scientist and a clinical psychologist at the U.S. National Institute of Mental Health. “We have every reason to believe that people with autism have higher estimates of suicide risk [than the general population],” she says, but “this is a tricky population to understand.”
In 2008, Horowitz led a multisite study to develop the Ask Suicide-Screening Questions tool, which has four questions and takes about 20 seconds to complete. Nurses or doctors refer anyone who answers ‘yes’ to one or more of the questions for further assessment. The tool was designed for typical youth aged 10 to 24, but last year, Lipkin and his colleagues began using it in their outpatient clinics at the Kennedy Krieger Institute in Baltimore.
The team offered the test to 317 autistic people aged 8 and older over two months in 2017. Roughly one in three of these people declined to take the test. Among the remaining participants, however, 13.7 percent screened positive for suicide risk. Autistic adults and parents of children with autism were more likely to decline the screen than were children and teens on the spectrum, the researchers reported at INSAR. The parents who did agree to the screen, however, were more likely to disclose suicidal behaviors than their children were — perhaps in part because children with autism can have trouble expressing themselves.
Another team has used the screen in the pediatric emergency room of Johns Hopkins Hospital in Baltimore. From May 2013 to December 2016, 42 percent of all autistic children admitted to the facility screened positive on the test; of these, 71 percent did not present with suicidal ideation. “We increase our detection of suicidal kids when we screen for it,” says Holly Wilcox, associate professor of mental health and psychiatry at Johns Hopkins University. “It gives us a window of opportunity to help them if we can link them up with appropriate services. Oftentimes, the suicidal individual will feel relieved that they were asked and they could disclose their thoughts.”
Parents sometimes worry that asking children about suicide can put ideas into their head, Horowitz says, but in the typical population, that is unquestionably a myth. “There are at least four studies refuting that you can make someone think about suicide by asking them,” she says. Still, she says, “we should test [that] out in the autism population, because sometimes people with autism can get stuck on ideas.” Depending on what the studies find, scientists may need to create screening guidelines specific to this group. Horowitz is also working to adapt the screen for people with autism who have trouble with social communication and may not be able to answer the questions as readily as typical people do.
Of course, not everyone who screens positive based on the four questions is truly at risk. Any accurate picture calls for an in-depth assessment using a developmentally sensitive approach, says Roma A. Vasa, director of psychiatric services at the Center for Autism and Related Disorders at Kennedy Krieger.
Kennedy Krieger. “When asking questions, we need to take into consideration the individual’s social, cognitive and communication challenges,” Vasa says. Clinicians need to evaluate whether people with autism also have depression or anxiety, and whether they have experienced stressful events: “It is important to understand how they perceive their social world and whether they feel integrated or isolated,” Vasa says.
It may also be important to enlist parents’ help when dealing with an autistic child. “No one else can be attuned to the small change in a child’s behavior,” says Ruth Gerson, assistant professor of child and adolescent psychiatry at New York University. “I really encourage parents to trust their own judgment and take any concerns that they see in their child seriously.” If a child is thinking about or engaging in suicidal behaviors, parents should immediately take her to a mental health practitioner or clinician who knows her — or, failing that, to the emergency room, where they should make it clear that their child is on the spectrum.
McIlwain monitors Connor’s moods carefully. Sudden, abrupt noises, the sound of radios and televisions, and even certain words can throw Connor into extreme panic. His mother is so concerned for his safety that she tries to shield him from any triggers. In April, the McIlwains bought the house next door to make it easier to separate Connor from his 10-year-old sister, particularly when she plays with her friends or practices her violin.
Ultimately, they hope to build an addition onto their new home so they can all live together again. But having the extra space next door is already helping. Because Connor can find peace and quiet when he needs to, he has more good days than bad, and over the past two months, hasn’t once attempted to run into the street.
Instead of doing schoolwork, Connor spends his time writing about animated movies he has researched online. He has compiled two books, which his parents have had printed. “It gives him a sense of purpose,” his mother says, “and something to look forward to.”
If you or someone you know is having suicidal thoughts, help is available. Click here for a worldwide directory of resources and hotlines that you can call for support.