Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-022-05575-2

BRIEF REPORT

Brief Report: Exploratory Evaluation of Clinical Features Associated

with Suicidal Ideation in Youth with Autism Spectrum Disorder
Kimberly S. Ellison1,2 · Elzbieta Jarzabek1 · Scott L. J. Jackson1,3 · Adam Naples1 · James C. McPartland1 

Accepted: 13 April 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
There has been a heightened awareness of an increased risk of suicidality among individuals with autism spectrum disorder
(ASD) due to high rates of suicidal ideation (SI) in this population (11–66%). The current study investigated the rate of
parent-endorsed SI and associated clinical features in 48 youths with ASD (Age; M: 12.97 years, SD: 2.33). SI was endorsed
in 18.75% of participants. Youth with SI exhibited significantly higher levels of affective problems, externalizing problems,
feelings of humiliation and rejection, and symptoms related to perfectionism. Results indicate that co-occurring mental
health problems are associated with suicidal ideation and provide relevant targets for psychotherapeutic intervention. This
preliminary study in a modest sample suggests the value of further research in larger samples to replicate and generalize
these findings.

Keywords  Autism spectrum disorder · Suicidal ideation · Suicide risk · Risk factors · Youth

Autism spectrum disorder (ASD) is a heterogeneous neu-
rodevelopmental condition that manifests in childhood and
is characterized by a dyad of core features: (1) challenges
with social emotional reciprocity and social communica-
tion and (2) restricted interests, unusual sensory responses,
and repetitive behaviors (American Psychiatric Association,
2013). Co-occurring psychiatric difficulties, such as depres-
sion and anxiety (Mannion et al., 2014; Mukaddes & Fateh,
2010) are common in ASD and are predisposing factors for
suicide (Gould et al., 1996; Kashani et al., 1989). Despite its
critical relevance to ASD, suicidality is poorly understood
in this population.
Suicidal ideation (SI) is recognized as an emergent con-
cern in the general population and in psychiatric conditions
other than autism. The age-adjusted suicide rate between
1999 and 2016 has increased 28% (from 10.5 to 13.4 per
* James C. McPartland
james.mcpartland@yale.edu
1
Child Study Center, School of Medicine, Yale University, 40
Temple Street, Suite 6A2, New Haven, CT 06520, USA
2
Department of Psychology, Louisiana State University, 236
Audubon Hall, Baton Rouge, LA 70803, USA
3
Office of Assessment and Analytics, Southern Connecticut
State University, 501 Crescent Street, New Haven, CT 06515,
USA
100,000 individuals) in the last 17 years (National Institute
of Mental Health (NIMH), 2018). In 2016, suicide was the
second leading cause of death in youth between the ages of
10–24 (Curtin et al., 2016; NIMH: Suicide, 2018). Parent
report indicates that frequency of SI or suicide attempts is
significantly greater for individuals with psychiatric con-
ditions (Mayes et al., 2015) and that individuals with SI
exhibit significantly elevated rates of co-occurring psycho-
pathology (e.g., mood, anxiety, and disruptive disorders)
compared to nonsuicidal youths (Gould et al., 1996; Kashani
et al., 1989; Mayes et al., 2015). Self-report reveals similar
relationships, with child-reported SI and co-occurring psy-
chiatric symptoms associated with depression and anxiety
(Kashani et al., 1989; Pezzimenti et al., 2019; Wijnhoven
et al., 2019) as well as aggressiveness and social difficulties
(Gould et al., 1996). Social communication difficulties are
associated with higher risk for suicidal thoughts and suicidal
plans (Culpin et al., 2018). Consequently, youth who have
social challenges by virtue of having ASD, in addition to
internalizing and/or externalizing problems, may be even at
higher risk for developing SI.
The increased risk in ASD for co-occurring psychi-
atric conditions may indicate increased risk for SI and
related behaviors (Hess et al., 2010). Nevertheless, the
body of research studying SI in ASD is limited and has
yielded inconsistent findings and utilized inconsistent

13
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methodologies (Cha et al., 2018; Gould et al., 1996; Mayes
et al., 2015). Estimates of SI in ASD vary drastically, with
rates ranging from 9.6 to 66% (Hedley & Uljarević, 2018;
Hunsche et al., 2020; La Buissonnière Ariza et al., 2021).
Contributing to this wide range in estimates may be the
large age span across studies, with youth ranging from 6
to 24 years old (Cassidy et al., 2014; Hedley & Uljarević,
2018; Hunsche et al., 2020; Mukaddes & Fateh, 2010;
Storch et al., 2013).
As in typical development, being male and an older
adolescent constitute risk factors associated with SI in
ASD (Brent et  al., 1999; Cassidy et  al., 2014; Mayes
et al., 2013; McDonnell et al., 2020). Likewise, non-demo-
graphic risk factors established in typically developing
individuals apply to youth with ASD including: the pres-
ence of comorbid psychopathology (Cassidy et al., 2014;
Hirvikoski et al., 2020; Mayes et al., 2013; McDonnell
et al., 2020; Mukaddes & Fateh, 2010), impulsive/aggres-
sive tendencies (Kanne & Mazurek, 2011), social isolation
and bullying (Hedley et al., 2018; van Roekel et al., 2010;
Zeedyk et al., 2014), and genetic factors (Hirvikoski et al.,
2020). In a recent examination of risk factors for suicide
in ASD, females with ASD without comorbid intellectual
disability were found to be at the highest risk for suicide,
whereas both genders had the highest risk when presenting
with comorbid Attention-Deficit/Hyperactivity Disorder
(Hirvikoski et al., 2020). The relationship of autism symp-
tom severity and SI has not been consistent across studies
(Mayes et al., 2013; McDonnell et al., 2020; Storch et al.,
2013); although children having fewer ASD symptoms has
been found to be associated with less SI (Hunsche et al.,
2020). Nevertheless, a diagnosis of ASD increases risk of
suicide attempts regardless of the presence of comorbid
psychopathology in adolescents and young adults (Chen
et al., 2017; Moses, 2017). Additionally, relatives of indi-
viduals with ASD were found to have higher risk for sui-
cidal behavior than relatives of controls (Hirvikoski et al.,
2020); further demonstrating that impact of having ASD
on not only the individual themselves but also the extent
on close family members.
Only 1 of 13 studies included in a recent review of
suicidality and ASD used “gold standard” diagnostic
tools (i.e., Autism Diagnostic Observation Schedule, Sec-
ond Edition (ADOS-2;Lord et al., 2002), and the Autism
Diagnostic Interview, Revised (ADI-R; Rutter et al., 2003))
(Hedley et al., 2018; Storch et al., 2013). Further, only
three recent studies published after this review utilized
the ADOS-2 for characterization (Hunsche et al., 2020; La
Buissonnière Ariza et al., 2021; McDonnell et al., 2020).
The vast majority of studies rely on caregiver report, with
few integrating caregiver and child report to comprehen-
sively evaluate the presence of SI (Storch et al., 2013).
13
Journal of Autism and Developmental Disorders
Even fewer studies have used clinician-administered inter-
views or formal suicide risk assessments to confirm the
existence of SI (Hedley & Uljarević, 2018).
The purpose of this study was to advance understanding
of SI in youth with ASD by addressing several of these
limitations of previous research. Rather than relying on
caregiver or self-report measures alone, we integrated both
to determine both parent and child experience of emo-
tional, behavioral, and anxiety-related problems. Addition-
ally, we integrated clinician-administered comprehensive
risk assessments with both the child and caregiver to con-
firm SI. We ensured that all youth met rigorous research
diagnostic criteria for ASD. Aligning with prevailing theo-
ries of SI in typical development, (the cognitive model and
the integrated motivational-volitional model (O’Connor &
Kirtley, 2018; Wenzel & Beck, 2008), we anticipated that
both dispositional vulnerability factors (e.g., depression,
behavioral rigidity) and cognitive processes (e.g., anxious
coping) would contribute to SI in youths with ASD.
Methods
Participants
The sample for this exploratory study was comprised of
48 youths with ASD participating in ongoing research at
the Yale Child Study Center in New Haven, Connecticut.
Exclusionary criteria included current use of benzodiaz-
epine or anticonvulsant medication; a history of seizures
or head injuries; primary psychiatric diagnosis that was
not ASD; full scale IQ < 70, as measured by the Differen-
tial Ability Scales, 2nd Edition (DAS-II; Elliott, 2007) or
other factors that would preclude successful data collec-
tion. Participants with ASD were diagnosed using gold
standard research tools, including the Autism Diagnostic
Observation Schedule 2nd Edition (ADOS-2; Lord et al.,
2002)) and Autism Diagnostic Interview Revised (ADI-R;
Rutter et al., 2003), administered by a research-reliable
administrator; all participants received a DSM-5 diagnosis
by a licensed clinician. ADOS-2 Comparison Scores (CS)
for those individuals who received an ADOS-2, Module 4
were calculated using the revised ADOS-2 DSM-5-based
algorithm (Hus & Lord, 2014). Demographic informa-
tion (e.g., age, sex, ethnicity), the SRS-2, CBCL/6–18,
and MASC-P were completed by a primary caregiver. The
participant completed the MASC-C questionnaire. Study
procedures were reviewed and approved by the university
institutional review board. All parents and youth who took
part in the study provided written informed consent or
assent (respectively) prior to participation.
Journal of Autism and Developmental Disorders
Determination of SI
Presence of SI was determined by caregiver-report of
whether their child “talks about killing self” over the
past 6 months, as reported on item 91 of the CBCL/6–18.
Suicidal ideation was considered present if the caregivers
responded to this item with either “Somewhat or Some-
times True” or “Very True or Often True.” If endorsed,
a clinician verified the presence of SI by conducting a
thorough risk assessment with both the caregiver(s) and
the child. The risk assessment procedure utilized was a
combination of (a) the Columbia Suicide Severity Rat-
ing Scale (CSSR-S; Posner et al., 2008) a standardized
interview that assessed the individual’s current level
and intensity of suicidal ideation, intent to harm oneself
(e.g., an active or passive plan, access to means), and sui-
cidal behavior (i.e., previous attempts) and (b) follow-up
questions pertaining to related risk factors (e.g., stress-
ful life events, amount of social support). The CSSR-S
was applied as a clinical information-gathering tool to
assist clinicians in assessing the level of risk the par-
ticipant posed at that current time; quantitative data from
the CSSR-S were not used in the present analysis. The
risk assessments were conducted by either licensed clini-
cal psychologists or by a masters-level clinician under
the direct supervision of a licensed clinical psychologist
who consulted and reviewed the risk assessments to make
the final determination. In all cases, presence of SI was
confirmed with both the caregiver(s) and the child based
upon the risk assessment described above.
Materials
Social Responsiveness Scale, 2nd Edition, School‑Age Form
(SRS‑2; Constantino & Gruber, 2012)
This caregiver-report measure is comprised of 65 state-
ments (e.g., “Is able to communicate his or her feeling
to others.”/“Seems overly sensitive to sounds, textures,
or smells.”) that caregivers rate on how well the state-
ment describes the behavior of their child over the past
6 months on a 4-point Likert-type scale ranging from 1
(Not True) to 4 (Almost Always True). Items on the SRS-2
were developed to assess ASD-related symptoms associ-
ated with social communication and interaction abilities,
as well as restricted interests and repetitive behaviors.
Total scores on the SRS-2 are translated into T-scores
(μ = 50, σ = 10), with higher scores representing the pres-
ence of increased levels of ASD-related symptoms. Psy-
chometric properties for the SRS-2 have been established
in previous studies (Constantino & Gruber, 2012; Reszka
et al., 2014).
Child Behavior Checklist for Ages 6–18 (CBCL/6–18;
Achenbach & Rescorla, 2001)
The CBCL/6–18 is a caregiver report instrument com-
prised of 113 statements (e.g., “Can’t sit still, restless,
or hyperactive.”/“Sudden changes in mood of feelings.”)
that caregivers’ rate on how well the statement describes
the behavior of their child over the past 6 months on a
3-point Likert-type scale ranging from 0 (Not True) to
2 (Very True or Often True). Items on the CBCL/6–18
were developed to provide assessment of specific syn-
drome scales and DSM-oriented scales. Higher scores on
the CBCL/6–18 scales represent the presence of increased
symptoms related to that specific emotional or behavioral
problem. Scores above 70 are considered to be clinically
significant. Psychometric properties for the CBCL/6–18
have been established in previous studies (Achenbach &
Rescorla, 2001; Achenbach et al., 2003). The analyses in
this study focus on the DSM-5 scales (i.e., Affective Prob-
lems, Attention-Deficit/Hyperactivity Problems, Anxiety
Problems, Conduct Problems, Oppositional Defiant Prob-
lems, and Somatic Problems), which we felt were most
conceptually relevant as well as relate to the dispositional
vulnerabilities associated with the cognitive model of
suicide.
Multidimensional Anxiety Scale for Children, Child‑Report
and Parent‑Report (MASC‑C and MASC‑P; March et al.,
1997)
Both the parent-report and the child-report versions of
the MASC were utilized to assess symptoms of anxiety.
Both versions of the MASC are comprised of 39 statements
(e.g., “I (My child) feel(s) tense or uptight.”/“The idea
of going away to camp would scare me (him/her)”) that
the informant will rate on how often the statement is true
based upon recent feelings on a 4-point Likert-type scale
ranging from 0 (Never True) to 3 (Often True). Items on
the MASC were developed to assess overall anxiety as well
as components of Physical Symptoms (i.e., Tense/Rest-
less, Somatic/Autonomic), Social Anxiety (i.e., Humilia-
tion/Rejection, Performance Fears), and Harm Avoidance
(i.e., Perfectionism, Anxious Coping). Higher scores for
the MASC subscales and total scores for each domain rep-
resent the presence of increased levels of symptoms of
anxiety. It is important to note that MASC-C T-scores and
MASC-P raw scores were utilized for analyses since there
are no established norms for the MASC-P. Psychometric
properties for the parent- and child-report versions of the
MASC have been established in previous studies (March
et al., 1997; Rynn et al., 2006).
13

Statistical Analysis
All statistical analyses were conducted using R. Given the
small sample size, bootstrap analysis was performed to avoid
the assumption of normality in the sample distribution. This
nonparametric statistical approach uses multiple small sam-
ples drawn from the original sample to estimate the sam-
pling distribution of the statistic through simulations, based
on sampling with replacement (Davison & Hinkley, 1997;
Efron & Tibshirani, 1993; Wright et al., 2011). Due the limi-
tation of the sample size, bootstrapping was utilized instead
of parametric statistical methods to ensure that a) there
was no violation of normality and b) the robustness of the
results (Carleton et al., 2012; Walters & Campbell, 2004).
Bootstrapping with 9999 sample replications was used to
calculate nonparametric 95% confidence intervals (CI) for
the difference in means for each scale (bias-corrected and
accelerated’ correction (BCa) was used on each confidence
interval). We report BCa means and corresponding stand-
ard errors along with mean of the bootstrapped values. We
adjusted for multiple comparisons using the Benjamíni-
Hochberg method; the False Discovery Rate utilized was
10% (Thissen et al., 2002).
Results
SI was endorsed for 18.75% (n = 9; 7 male; Mean
age = 12.97, SD = 2.33) of participants; correspondingly, 39
were reported not to have SI (16 male; Mean age = 13.77,
SD = 2.84). Ethnicity/race distributions for the ASD with
SI and ASD without SI groups are as follows: ASD with
SI (88.9% White/Caucasian, 11.1% Asian) and ASD with-
out SI (79.5% White/Caucasian, 10.3% Hispanic, 7.7%
Black, 2.6% Asian); these groups did not differ on ethnic-
ity/race (p = 0.29). Additionally, although the Full Scale-
IQ exclusion criteria for this study extended to as low as a
Table 1  Demographic comparisons
SI (n = 9) No SI (n = 39)
Gender
 Male (Female) 7(2) 33 (6)
Age range 8–17 years old 8–17 years old
Mean, SD M = 12.97, SD = 2.33 M = 13.77, SD = 2.84
DAS-2 verbal M = 107.11, SD = 19.88 M = 104.94, SD = 13.04
DAS-2 NVR M = 108.67, SD = 27.13 M = 104.49, SD = 14.72
DAS-2 spatial M = 102.11, SD = 21.40 M = 100.15, SD = 14.49
DAS-2 GCA​ M = 107.56, SD = 26.06 M = 103.79, SD = 13.08
SI suicidal ideation, DAS-II differential ability scales (2nd edition), NVR nonverbal reasoning, GCA​ general conceptual ability
*Based on Bootstrapping (BCa)
13
Journal of Autism and Developmental Disorders
standard score of 70, the lowest obtained Full Scale-IQ for
an included participant was a standard score of 84. As shown
in Table 1, youth with SI and those without SI did not differ
on IQ, age, sex, SRS-2 or ADOS-2 CS.
Clinical Features of Suicidal Ideation in ASD
Participants with ASD with reported SI were compared to
those with no reported SI across the DSM-oriented scales
of the CBCL/6–18, the parent- and child-report versions of
the MASC (MASC-P and MASC-C, respectively). Looking
specifically at the CBCL/6–18 DSM-oriented scales, youth
with SI obtained significantly higher scores on the Affec-
tive Problems, and Oppositional Defiant Problems. On the
MASC-C youth with SI had higher scores on the Perfec-
tionism subscale. According to parent report, individuals
with SI obtained higher scores on the Humiliation/Rejection
subscale (Table 2).
Discussion
This study examined frequency of endorsement of SI in a
sample of youth with ASD and explored associated clinical
features. Advancing from prior research on this topic, we
carefully characterized our sample using “gold-standard”
research tools (i.e., ADI-R and ADOS-2), integrated both
parent and child report, and confirmed SI by direct clini-
cian assessment. Results align with prior studies indicating
that SI is overrepresented in ASD compared to the general
population (Curtin et al., 2016; Hedley & Uljarević, 2018;
Mukaddes & Fateh, 2010; Shtayermman, 2008; Storch et al.,
2013). In our study, rates of suicidal ideation were signifi-
cantly higher in youth with ASD (18.75%) than in popula-
tion estimates of typically developing youth (4.27%; crude
rate of suicide injury deaths per 100,000, ages 8–17 from
the 2017 national mortality statistics from the Centers for
Mean group Benjamini–Hoch- Confidence intervals*
difference berg p-value
– – –
0.80 0.83 –
2.10 0.83 7.99, 19.68
4.22 0.83 11.35, 23.42
1.94 0.83 9.87, 17.73
3.76 0.83 9.23, 26.41
Journal of Autism and Developmental Disorders

Table 2  Clinical features
SI (n = 9) No SI (n = 39) Mean group diff Benjamini– Confidence intervals*
Hochberg
p-value

CBCL oppositional defiant probs M = 67.67, SD = 7.83 M = 56.82, SD = 7.20 10.85 0.03± 5.29, 16.15
CBCL affective probs M = 71.22, SD = 7.93 M = 61.51, SD = 7.79 9.71 0.04± 3.57, 14.67
MASC-P humiliation/rejection M = 11.13, SD = 2.90 M = 7.33, SD = 4.43 3.79 0.04± 1.30, 6.00
MASC-C perfectionism M = 65.75, SD = 6.32 M = 56.26, SD = 13.10 9.49 0.05± 2.72, 14.47
MASC-P tense/restless M = 9.13, SD = 4.52 M = 5.85, SD = 3.27 3.28 0.27 .03, 6.14
MASC-C public performance fears M = 48.25, SD = 10.82 M = 54.55, SD = 11.26 − 6.30 0.43 − 14.86, .75
MASC-P somatic/automatic M = 4.63, SD = 3.20 M = 2.67, SD = 3.51 1.96 0.50 .62, 4.08
CBCL anxiety probs M = 68.22, SD = 7.68 M = 63.64, SD = 8.70 4.58 0.50 1.53, 9.51
MASC-P anxious coping M = 10.13, SD = 1.36 M = 9.46, SD = 3.01 0.66 0.83 .61, 2.02
MASC-C tense/restless M = 57.63, SD = 7.58 M = 55.05, SD = 11.03 2.57 0.83 3.54, 8.62
MASC-P perfectionism M = 8.63, SD = 1.85 M = 9.13, SD = 1.70 − 0.50 0.83 − 1.91, .71
CBCL conduct probs M = 56.78, SD = 6.67 M = 55.59, SD = 6.65 1.19 0.83 2.69, 6.83
MASC-C somatic/automatic M = 48.00, SD = 6.28 M = 49.11, SD = 9.14 − 1.11 0.83 − 3.38, 6.41
MASC-C humiliation/rejection M = 49.63, SD = 13.32 M = 51.61, SD = 10.11 − 1.98 0.83 − 6.40, 12.29
MASC-C anxious coping M = 55.00, SD = 15.26 M = 57.00, SD = 9.91 − 2.00 0.83 − 11.72, 8.67
MASC-P public performance fears M = 7.25, SD = 2.71 M = 6.95, SD = 2.87 0.30 0.83 − 1.56, 2.38
CBCL ADHD probs M = 61.44, SD = 10.13 M = 60.72, SD = 7.61 0.72 0.83 5.74, 7.65
CBCL somatic probs M = 61.22, SD = 6.59 M = 57.26, SD = 8.80 3.97 0.83 1.44, 8.36
SRS-2 awareness M = 68.11, SD = 13.11 M = 67.28, SD = 12.04 0.78 0.83 7.42, 10.10
SRS-2 comm M = 75.67, SD = 14.71 M = 72.00, SD = 11.56 3.68 0.83 5.44, 13.73
SRS-2 cognition M = 69.56, SD = 12.28 M = 68.44, SD = 11.32 1.10 0.83 8.18, 8.76
SRS-2 motivation M = 72.22, SD = 10.08 M = 69.00, SD = 11.68 3.20 0.83 3.33, 11.94
SRS-2 RIRB M = 75.33, SD = 16.49 M = 71.21, SD = 14.32 4.08 0.83 7.17, 14.98
ADOS-2 CS M = 7.44, SD = 1.33 M = 7.31, SD = 1.91 0.13 0.83 0.92, 1.09

SI suicidal ideation, Diff difference, CBCL childhood behavior checklist, Probs problems, MASC-C/P, multidimensional anxiety scale for chil-
dren, child-report and parent-report, SRS-2 social responsiveness scale, 2nd Edition, Comm communication, RIRB restricted interests and repeti-
tive behavior, ADOS-2 CS autism diagnostic observation schedule, 2nd edition comparison scores
*Based on Bootstrapping (BCa)
±Significant at a False Discovery Rate of 10%

Disease Control and Prevention; (CDC, 2017; Mayes et al.,
2013)). Endorsement of SI in our sample was consistent with
previous research (Hedley et al., 2018) relying solely on car-
egiver report/with community diagnosis. Though previous
studies indicated higher SI among males and older adoles-
cents, (Brent et al., 1999; Mayes et al., 2013) there were
no significant differences between individuals with SI and
without SI with regard to demographic characteristics, such
as age, sex, and ethnicity in our sample. Autism symptom
severity, based on both parent and clinician report, was com-
parable among those with and without SI; this contrasts with
prior findings of less severe symptomatology being related
to SI (Brent et al., 1999; Mayes et al., 2013). This may be
due to our sample generally having homogenous levels of
autism symptoms with limited range.
With regard to clinical features of SI, our results support
previous findings that co-occurring mental health problems
are associated with suicidal ideation (Gould et al., 1996;
Kashani et al., 1989; Mayes et al., 2015). More specifically,
parents of individuals with SI reported significantly higher
levels of both internalizing and externalizing problems in
their children. With regard to internalizing problems, those
with SI were reported to display significantly greater lev-
els of affective problems (e.g., crying, feeling worthless,
being nervous, worrying, being self-conscious) aligning
with depression, a recognized correlate of SI in the general
population (Shtayermman, 2008).
Though anxiety symptoms were clinically elevated in the
ASD group, no significant differences were found in individ-
uals with and without SI. However, there were discrepancies
between self- and parent- report on the MASC-2. Signifi-
cantly higher levels of humiliation and feelings of rejection
were reported by parents of individuals with ASD with SI.
In contrast to parental perception, youths with SI did not
self-report feeling humiliated, rejected, but they reported
significantly higher levels of perfectionistic behaviors (e.g.,

13

trying hard to obey others, trying to do things other people
would like, and trying to do things exactly right).
With respect to theoretical accounts of the development
of suicidal ideation, our results align with both the cognitive
model of suicide (Wenzel & Beck, 2008) and the Integrated
Motivational-Volitional model of suicidal behavior (IMV;
O’Connor & Kirtley, 2018), providing limited discriminant
evidence for one of the other. The cognitive model of suicide
posits that suicidal behavior is based on dispositional vul-
nerabilities (trait-like psychological variables (e.g., impul-
sivity, neuroticism, and problem-solving impairments))
and cognitive processes (distorted perceptions of external
or internal events or stimuli which distorts and their impact
on experience) associated with both psychiatric disturbance
and suicidal behavior (Wenzel & Beck, 2008). The IMV
model delineates a motivation phase related to SI in contrast
to a volitional phase related to actual suicidal behavior; we
focused on the former as most relevant to this study. In the
motivational phase, predispositional factors and life expe-
riences (e.g., feelings of defeat, rejection and humiliation
engender feelings of entrapment) contribute to a baseline
suicide risk of SI (O’Connor & Kirtley, 2018). In ASD,
commonly experienced social isolation and peer rejection
(Hedley et al., 2018; van Roekel et al., 2010), as well as
cognitive rigidity may contribute to this process. In keeping
with the cognitive model of suicide (Wenzel & Beck, 2008),
challenges associated with ASD spectrum may confer risk
for experiencing suicidal thoughts both through dispositional
vulnerability factors associated with ASD (e.g., insistence
on sameness) as well as cognitive processes associated with
psychiatric distress (e.g., co-occurring anxiety and depres-
sion). As described by the IMV model (O’Connor & Kirt-
ley, 2018) we observed that experiences of humiliation and
rejection are relevant to the experience SI in youth with
ASD. Additional research in larger samples is warranted to
better elucidate theoretical models of development of SI in
youth with ASD.
There are several study limitations that should be
acknowledged. First, this study is exploratory and descrip-
tive and lacks a typically developing comparison group (the
larger study from which this data was obtained excluded typ-
ically developing participants with any psychiatric difficul-
ties). Similarly, co-occurring psychiatric diagnoses for the
participants with ASD were not formally assessed. Second,
suicidal ideation was operationalized based upon endorse-
ment of a single item on a caregiver-report scale and sub-
sequent verification by a clinician. It is possible that youth
with SI did not express suicidality to their caregivers, mak-
ing them unaware of the presence of SI when completing the
CBCL/6–18, could be miscategorized as into the no suicidal
ideation group. Future studies can address this weakness
by utilizing multiple measures across multiple informants
to assess the presence suicidal ideation. Third, anxiety
13
Journal of Autism and Developmental Disorders
was assessed via both caregiver and self-report, emotional
and behavioral functioning was based solely on caregiver
report. Future research should include self-report of emo-
tional and behavior problems such as the Youth Self-Report
(YSR; Achenbach & Rescorla, 2001) to further understand
the emotional experiences of individuals with ASD. Fifth,
our results are based on a small predominately white sample.
Though we were able to detect significant results, it will be
important to verify our findings in larger and more diverse
samples. Furthermore, our study did not formally assess
for co-occurring conditions and their possible impact on SI
in ASD, an important objective for future research. Lastly,
we solely explored the clinical features of SI in a sample
which had an overall IQ and verbal IQ over 80 in order to
ensure that participants would understand the questions on
the self-report measures of anxiety (MASC-C). Increasing
the IQ range for future studies is necessary to address SI in
individuals with ASD and lower cognitive ability.
This study provides information important for both clini-
cal practice and future research. Findings add to a growing
body of literature demonstrating increased SI in youths with
ASD and highlight the relevance of co-occurring emotional
and behavioral challenges to the presence of SI. Our integra-
tion of caregiver-report and self-report measures indicated
discrepancies in several areas and highlight the import of
integrating data across multiple informants in investigating
and assessing SI. In addition to these clinical metrics, future
studies should investigate potentially informative biologi-
cal differences between youth with ASD with SI and youth
with ASD without SI. Examining biological markers is an
important adjunct to parent/self-report in tracking SI risk
clinical factors/symptoms in ASD over time to determine if
particular interventions decrease SI in the ASD population.
Furthermore, recognizing that parents of youth with ASD
may be noticing their child’s affective difficulties as well as
their overt expression of feelings related to rejection may be
key in terms of identifying these youth who are at greater
risk for developing SI. Taken together, this study provides
important insight into the clinical features associated with
SI in ASD.
Author Contributions  Formal analysis was done by KSE, SLJ and AN.
Funding acquisition was done by SLJ and JCM. Investigation was done
by KSE and EJ. JCM done project administration. Resources, Supervi-
sion, Validation was done by JCM and AN. Visualization was done by
KSE and AN. Original draft preparation was done by KSE. Review &
editing was done by KSE, AN and JCM. All authors contributed to the
study's conception and methodology.
Funding  Funding for this manuscript was provided by the National
Institute of Mental Health (R01 MH100173, U19 MH108206, R01
MH107426). Scott Jackson received funding through the National Insti-
tute of Mental Health (T32 MH18268).
Journal of Autism and Developmental Disorders
Declarations  American Academy of Child & Adolescent Psychiatry, 57(5), 313-
Conflict of interest  James C. McPartland consults with Customer Val-
ue Partners, Bridgebio, Determined Health, and BlackThorn Thera-
peutics, has received research funding from Janssen Research and De-
velopment, serves on the Scientific Advisory Boards of Pastorus and
Modern Clinics, and receives royalties from Guilford Press, Lambert,
and Springer.
Ethical Approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standard.
Informed Consent  Informed consent was obtained from all individual
participants included in the study.
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