Clinical Psychology Review 99 (2023) 102235

Contents lists available at ScienceDirect

Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

A systematic review of predictors of suicidal thoughts and behaviors among

autistic adults: Making the case for the role of social connection as a
protective factor
Annabelle M. Mournet a, *, Ellen Wilkinson a, Vanessa H. Bal b, Evan M. Kleiman a
a
Rutgers, The State University of New Jersey, United States
b
Graduate School of Applied and Professional Psychology, Rutgers University, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Autistic adults are a high-risk population for suicidal thoughts and behaviors (STBs). Accordingly, this systematic
Suicidal thoughts and behaviors review aims to review the prevalence of STBs among autistic adults, review the risk and protective factors for
Autism STBs in autistic adults, and formulate a disorder-specific conceptualization of risk in this population. We sys­
Adults
tematically searched PsycINFO and Google Scholar for all studies published prior to March 28th, 2022. We
Social connection
included empirical articles focused on autistic adults, ages 18 years and older, reporting on suicide-related
Depressive symptoms
outcomes. In total, 45 peer-reviewed empirical articles were included in the current systematic review. The
most frequently studied factors in relation to suicide risk among autistic adults were interpersonal constructs
(42.4% of total studies looking at risk/protective factors) and depressive symptoms (36.4% of total studies
looking at risk/protective factors). We conclude by summarize two key content areas: exploring social and
interpersonal constructs and better understanding the role of depressive symptoms in autism. As researchers
continue to explore STBs among autistic adults, it will be necessary to addressing the overreliance on autistic
symptoms instead of autism diagnoses, measurement issues of STBs, and a need for treatment adaptations.

Suicide is a global public health crisis and ranks as a top ten leading
cause of death across age groups in the United States (US; Centers for
Disease Control and Prevention, 2018). Over 45,000 adults in the US
died from suicide in 2019 alone (Centers for Disease Control and Pre­
vention, 2018). Considerable research has been devoted to studying
suicide risk, including the study of protective factors against suicide risk,
such as social connectedness (Czyz, Liu, & King, 2012; Kleiman & Liu,
2013). Most conceptualizations of suicide risk and resilience are framed
for largely heterogeneous populations, rather than for specific high-risk
populations. This approach implicitly assumes that risk factors in one
high-risk group function similarly in another high-risk group and hin­
ders our ability to understand population-specific risk. Accordingly, the
goals of this manuscript are: (1) to review the prevalence of suicidal
thoughts and behaviors (STBs) among autistic adults, a unique yet
understudied high-risk population (Ludi et al., 2012), (2) review the risk
and protective factors for STBs in autistic adults, and (3) formulate a
disorder-specific conceptualization of risk in this population.
To formulate a conceptualization of suicide risk among autistic
adults, it is necessary to consider the existing theoretical foundations
surrounding suicide. Numerous theories to explain suicidal ideation,
behavior, and death by suicide have been proposed. These theories
range from centering around interpersonal risk factors, such as the
Interpersonal Theory of Suicide (IPTS; Joiner, 2005; Van Orden et al.,
2010) to theories emphasizing hopelessness and psychological pain as
the drivers of a desire to die by suicide (Abramson et al., 2000;
Shneidman, 1993). More recently, some theories of sought to created
integrated theories of suicide that account for numerous potential mo­
tivators for a desire to die by suicide, such as O’Connor and Kirtley
(2018) integrated motivational–volitional (IMV) model of suicidal
behavior as well as the three-step theory (3ST) of suicide (Klonsky,
Pachkowski, Shahnaz, & May, 2021). For instance, the IMV theory in­
cludes access to lethal means, exposure to suicidal behavior, capability
for suicide, impulsivity, and past suicidal behavior. It will be important
to consider the extent to which existing research on suicidal thoughts
and behaviors among autistic adults consider and investigate the role of
the variables hypothesized to drive the desire to die by suicide across
these numerous existing theories.
While there are several review papers on suicide among autistic

* Corresponding author at: Department of Psychology, Rutgers, The State University of New Jersey.
E-mail address: amm883@psych.rutgers.edu (A.M. Mournet).

https://doi.org/10.1016/j.cpr.2022.102235
Received 28 March 2022; Received in revised form 21 September 2022; Accepted 23 November 2022
Available online 28 November 2022
0272-7358/© 2022 Elsevier Ltd. All rights reserved.
A.M. Mournet et al.
individuals, these papers have focused only on adolescents and young
adults (Hannon & Taylor, 2013; O’Halloran, Coey, & Wilson, 2022), or
have included all ages (Hedley & Uljarević, 2018; Richa, Fahed, Khoury,
& Mishara, 2014; Segers & Rawana, 2014; Zahid & Upthegrove, 2017).
Among a youth sample, the recent review by O’Halloran et al. (2022)
found that roughly a quarter of autistic youth experienced suicidal
ideation and one in ten had a history of suicide attempts, with bullying
and other adverse childhood experiences found to be considerable risk
factors. Across ages, Hedley and Uljarević (2018) found that for autistic
individuals, prevalence rates of suicidal ideation were 11–66% and the
prevalence of suicidal attempts were 1–35%. Existing systematic re­
views have demonstrated the heightened risk of suicidal thoughts and
behaviors among autistic individuals across this lifespan and among
young people in particular, however, in other areas of suicide research,
adolescents and adults are often seen as distinct populations with
distinct risk factors (Safer, 1997). Thus, with work in suicide and autism
assuming heterogeneity over developmental periods leaves a consider­
able gap in the understanding of suicide among autistic adults (Murphy
et al., 2016).
1. Method
This systematic review, registered with PROSPERO, was conducted
in PsycINFO, through Ovid, to search for articles published prior to
September 10th, 2022. This systematic review was prepared in accor­
dance with the Preferred Reporting Items for Systematic reviews and
Meta-analyses (PRISMA) standards (Page et al., 2021). The search terms
were (autism or autistic or ASD or Asperger* or pervasive developmental
disorder) and (suic*). The literature search was further limited to peer-
reviewed articles of studies where the mean age was over the age of
18 years old or the age range was predominantly older than 18 years old.
One coder (A. M.) reviewed the articles for eligibility and an additional
coder (E. K.) reviewed all articles to corroborate all coding decisions.
Any discrepancies were resolved during coding meetings. The search
was supplemented with articles from google scholar as well as by
reviewing the references from all included articles.
Eligible peer-reviewed empirical articles included the following: (1)
contained a suicide-related outcome (i.e., suicidal thoughts, suicidal
behaviors), (2) included an autistic sample or subsample, and (3) had a
mean age of at least 18 years old or the age range was predominantly
older than 18 years old. Articles were excluded from this review based
on the following criteria: (1) non-empirical peer-reviewed papers (i.e.,
commentaries, systematic reviews, study protocols with no data, dis­
sertations), (2) case studies (a total of five people with autism was
needed in order to be included), (3) no suicide-related outcome (e.g.,
non-suicidal self-injury, euthanasia and assisted suicide), (4) absence of
an autistic sample or subsample (e.g., examining only autistic traits or
symptoms, rather than diagnoses of autism), (5) consisted of a sample
where the mean age was less than 18 years old or the age range was
predominantly under the age of 18 years old, and (6) included both a
suicide outcome and an autistic sample, but the analyses did not link the
two. After the initial search was run, a post-hoc decision was made to
exclude articles where the study aim was to adapt existing measures and
treatments for use among autistic adults due to few articles (N = 3) being
published on these topics.
A modified version of the Newcastle-Ottawa Scale (NOS; Wells et al.,
2000) was used to perform a risk of bias assessment, emphasizing the
following criteria: (1) sample representativeness, (2) sample size, (3)
comparability between respondent and non-respondent characteristics,
(4) ascertainment of suicidal thoughts and/or behaviors, and (5) quality
of descriptive statistics reporting. Items were modified to mirror the
aims of the current systematic review (Zeng et al., 2015). In keeping
with existing systematic reviews on the topic of suicidal thoughts and
behaviors among autistic individuals, rating items were developed in
alignment with the criteria laid out by O’Halloran et al. (2022) in their
review of suicide risk among autistic youth. Ratings were assigned to
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Clinical Psychology Review 99 (2023) 102235
each study with summary scores of risk of bias ranging from 0 (high risk
of bias) to 5 (low risk of bias). Studies with 0 or 1 points were classified
as high risk of bias studies, studies with 2 or 3 points were classified as
medium risk of bias, whereas studies with 4 or 5 points were considered
low risk of bias studies. The rating procedure is reported as in Fig. 1.
Regardless of risk of bias scores, all studies were retained in the review.
2. Results
The search yielded 184 articles for initial review, with a sample of 31
articles deemed eligible (16.8%). Fourteen additional articles that did
not appear in the PsycINFO search were deemed eligible as a result of
reviewing the citations of the eligible articles and through Google
Scholar. Six of these 14 articles (42.9%; 6/14) were published in 2021 or
2022, likely resulting in these papers not appearing in the PsycINFO
search. In total, 45 peer-reviewed empirical articles were included in the
current systematic review (see Fig. 2 for PRISMA diagram and Table 1
for a summary of all included articles, including participant summaries
for all studies). The first included article was published in 1994 (Lain­
hart & Folstein, 1994), with the next oldest included article published in
2006 (Wahlund & Kristiansson, 2006). The modal years of publication
for included articles was 2020 and 2021 (N = 10). Fig. 3 provides a bar
chart of the publication year of all articles included in this review. The
risk of bias assessment revealed that 42.2% (19/45) of studies had low
risk of bias, 55.6% (25/45) of studied had medium risk of bias, and 2.2%
(1/45) of studies had high risk of bias.
A total of 25 articles (55.6%; 25/45) were authored by 8 distinct
groups of authors with multiple publications. The author group with the
greatest number of included articles was Baron-Cohen, Cassidy, Pelton,
and colleagues, with 9 relevant articles. The next most common group of
authors was Hedley and colleagues, with 5 relevant articles. The
remaining 20 articles (45.4%; 20/45) were published by distinct groups
of authors, with each of these sets of authors publishing one article that
was included in this search.
2.1. Prevalence
Five studies have reported prevalence rates of suicidal ideation
among autistic adults, ranging from 16% in a community-based sample
of 277 participants (Bradley, Shaw, Baron-Cohen, & Cassidy, 2021) to
66% in a clinically ascertained sample of 367 participants (Cassidy et al.,
2014). Rates of lifetime suicide attempts among autistic adults have also
been found to vary, with one study of autistic university students
reporting one participant with a suicide attempt (1%; Anderson, Carter,
& Stephenson, 2020) ranging to a 37% suicide attempt rate among a
sample of autistic adults recruited from an online autism research
database (Bradley et al., 2021). In a systematic review of 17 published
case studies of autistic adults, two individuals (11.8%; 2/17) had STBs
(Lainhart & Folstein, 1994). More recently, a small study of 26 autistic
adults that presented to a psychiatric setting detected a 31% suicidal
ideation rate and an 11.5% history of suicide attempt rate, of which two
out of three suicide attempters died by suicide (Raja, Azzoni, & Frustaci,
2011). Using surveillance data from one US state, researchers found that
between 2013 and 2017 the cumulative suicide incidence rate among
autistic individuals was 0.17% and was significantly greater than the
incidence of suicide among the non-autistic population (Kirby et al.,
2019).
2.1.1. Comparison of STB prevalence in autistic versus non-autistic adults
A handful of studies have compared the likelihood of STBs among
adults with and without autism. In all of these studies (6/6), autistic
adults were significantly more likely to experience STBs than non-
autistic adults (i.e., suicidal ideation: Vohra, Madhavan, & Samba­
moorthi, 2016; suicide attempts: Chen et al., 2017; Hand, Angell, Harris,
& Carpenter, 2020; Takara & Kondo, 2014a; suicide deaths: Hirvikoski
et al., 2016). Among a sample of transgender young adults recruited
A.M. Mournet et al. Clinical Psychology Review 99 (2023) 102235

Fig. 1. Adapted Newcastle-Ottawa Scale (NOS) rating procedure.

Note: For each study, scores on the criteria above are summed to compute a total risk of bias score, with totals ranging from 0 to 5. Modifications of the NOS rating
procedure are based on the adaptations of O’Halloran et al. (2022).

Fig. 2. PRISMA diagram.

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A.M. Mournet et al. Clinical Psychology Review 99 (2023) 102235

Table 1
Summary of included articles (N = 44).*
Authors (Year) Sample size & description Sample age Autism conceptualization STB-related factors Prevalence and/or examined Risk
mean (SD) factors of bias
score

Anderson et al. 102 autistic university
(2020) students; 77 respondents for
STB-related items
Arwert and Sizoo 75 psychiatric outpatient
(2020) autistic adults
Bradley et al. 277 autistic adults from an
(2021) online autism research
database
Camm-Crosbie 200 autistic adults recruited
et al. (2019) from the Cambridge Autism
Research Database
Cassidy et al. 374 adults with AS from a
(2014) specialist diagnostic clinic
Cassidy, Bradley, 164 autistic adults from an
Shaw, and online autism research
Baron-Cohen database
(2018) 169 general population
adults
Chen et al. (2017) 5618 autistic adolescents
and young adults
22,472 non-autistic controls
Costa et al. (2020) 150 autistic adults
189 non-autistic adults
Croen et al. (2015) 1507 autistic adults
15,070 non-autistic adults
Dell’Osso et al. 34 autistic adults without
(2018) intellectual impairment
68 adults fulfilling one
symptom criteria for ASD
160 healthy controls
Docherty et al. 18,223 suicide decedents in
(2020) one U.S. state
Dow et al. (2021) 98 autistic adults recruited
through universities
Gilmore, Harris, 2054 autistic older adults
Longo, and with intellectual disability
Hand (2021) 2631 autistic older adults
without intellectual
disability
Hand, Angell, et al. 4685 autistic older adults
(2020) 46,850 match population
comparison
Hand, Benevides, 21,792 autistic adults
and Carretta enrolled in Medicaid
(2020)
65% ages Formal diagnosis of ASD Thoughts about 48% had thought about suicide, 1
18–24 years suicide, suicide 12% had made plans to attempt
35% ages 25 plans, suicide suicide, 1% attempted suicide
years or above attempts
35.89 (12.96) Diagnosis of ASD by experienced Suicidal ideation Self-esteem, rumination 4
clinicians
Males Self-reported a diagnosis of an SBQ-R total score, 16% rate of suicidal ideation 4
diagnosed with ASC or self-identified as autistic lifetime suicidal 37% suicide attempt rate
ASC: 42 ideation, lifetime
(11.65) suicide plan, lifetime
Females suicide attempt
diagnosed with
ASC: 36.42
(10.57)
Males self-
identified with
ASC: 36.57
(9.83)
Females self-
identified with
ASC: 39.34
(8.64)
38.9 (11.5) Autism diagnosis without co- Thoughts about Accessibility of mental health 2
occurring intellectual disability suicide, suicide treatment and services
attempts
31.5 (10.9) Diagnosis of AS by an expert Suicidal ideation, 66% reported suicidal ideation, 3
clinician suicide plans, suicide 35% reported suicide plans or
attempts suicide attempts
Age range: Self-reported a diagnosis of ASC SBQ-R total score, Non-suicidal self-injury, 3
20–60 years from a trained clinician lifetime suicidal camouflaging, unmet support
old ideation, lifetime needs
suicide plan, lifetime
suicide attempt
ASD group: Diagnosed with ASD by board- Suicide attempts Patients with ASD had a higher 3
17.20 (4.58) certified psychiatrists incidence of suicide attempts
Control group: (3.9% vs 0.7%, P < .001) than
17.20 (4.58) those without ASD
ASD group: Self-reported diagnosis of ASD SBQ-R total score Autistic traits, depressive 4
33.74 (11.81) (lifetime suicidal symptomatology, antidepressant
Control group: ideation, lifetime intake
27.84 (8.55) suicide plan, lifetime
suicide attempt)
ASD group: 29 Diagnosis of ASD recorded in Suicide attempts Depression 5
(12.2) Kaiser Permanente in Northern
Control group: California EMR on at least two
29.4 (12.1) separate occasions
25.7 (8.9) DSM-5 criteria Suicide risk score Mood symptoms, autistic traits 5
based on suicidal
ideation and suicide
attempts
ASD diagnosis Suicide deaths The suicide death sample was 3
found to have increased genetic
risk for ASD
28.2 (10.9) ASD diagnosis confirmed by a DSI-SS total score Thwarted belonging, perceived 4
license professional (suicidal ideation) burden, loneliness, social
dissatisfaction, depression,
anxiety
Age: 65 years At least one inpatient or Suicidal ideation Intellectual disability 4
and older outpatient encounter with an
ASD diagnosis
Age: 65 years At least one inpatient or Medical encounter STB or self-inflicted injury was 4
and older outpatient encounter with an for STB or other more common among autistic
ASD diagnosis intentional self- older adults (odds ratio = 11.1;
injury 95% confidence interval =
8.9–13.8)
Median age: 35 At least one Medicare claim for Suicidal ideation, Younger age, White race, 5
IQR: 26–46 an inpatient or outpatient suicide attempts depression disorders, psychiatric
Age range: encounter with an autism healthcare utilization
18–59 diagnosis
(continued on next page)

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A.M. Mournet et al.
Table 1 (continued )
Authors (Year) Sample size & description
Hedley, Hayward, 111 autistic adults recruited
et al. (2021) through an emailed
newsletter
Hedley, Uljarević, 1851 adults from Survey
et al. (2021) Sampling International
Hedley, Uljarević, 185 autistic people recruited
Wilmot, et al. through support groups,
(2018) universities, and social
media
Hedley et al. 76 autistic adults recruited
(2017) online
Hedley, Uljarević, 71 autistic adults recruited
Foley, et al. through support groups,
(2018) universities, and social
media
Hirvikoski et al. 43,570 autistic individuals
(2020) without ID
10,598 autistic individuals
with ID
1,735,775 control relatives
Hirvikoski et al. 27,122 ASD probands from a
(2016) national patient register
2,672,185 matched controls
from a national patient
register
Hooijer and Sizoo 74 psychiatric outpatient
(2020) autistic adults
Jachyra et al. 16 autistic adults in a
(2021) psychiatric emergency
department
Jackson et al. 56 autistic adults recruited
(2018) online
Kato et al. (2013) 43 autistic adults
544 non-autistic adults
Admitted to a psychiatric
hospital
Kirby et al. (2019) 16,904 autistic individuals
who died by suicide in one U.
S. state
Lainhart and 17 published case studies of
Folstein (1994) autistic individuals
Moseley et al. 103 autistic participants
(2020) recruited from Facebook
support groups for autistic
adults
Moseley et al. 314 autistic adults recruited
(2022) online
Paquette-Smith 50 adults with AS recruited
et al. (2014) from AS and autism
advocacy organizations and
websites
Pelton et al. 350 autistic people
(2020a) 339 non-autistic people
Recruited through research
databases
Radoeva et al. 58 autistic adults from a
(2021) medical record chart review
Raja et al. (2011)
Clinical Psychology Review 99 (2023) 102235
Sample age Autism conceptualization STB-related factors Prevalence and/or examined Risk
mean (SD) factors of bias
score
42.45 (13.03) Formal diagnosis of autism SBQ-R total score Impact of COVID-19 4
(lifetime suicidal
ideation, lifetime
suicide plan, lifetime
suicide attempt)
37.09 (12.28) Self-report diagnosis of autism Suicidal ideation Autism symptoms, depression 3
36.69 (15.57) Self-report of a clinical diagnosis Suicidal ideation Loneliness, satisfaction with 3
Age range: of ASD social support, ASD traits,
14–80 depression
25.25 (7.74) ASD diagnosis confirmed by Suicidal ideation Social support in the form of 3
general practitioner appraisal and belonging,
perceived availability of tangible
(material) support, depression
26.14 (8.20) ASD diagnosis confirmed by Thoughts of being Loneliness, autistic traits, 3
general practitioner better off dead or depression
hurting oneself
Not available ICD diagnosis codes for any ASD Suicidal behaviors Intellectual disability, gender, 4
attention-deficit/hyperactivity
disorder
Not available ICD diagnosis codes for any ASD Suicide deaths The ASD group was 7.55 (95% CI 3
= 6.04–9.44) times more likely to
die by suicide in comparison with
matched general population
controls
28.5 Diagnosis with ASD according to BSS (suicidal Depression, temperament 5
Age range: the DSM-IV criteria by qualified ideation)
23–42 years clinicians
Ages 18 and Clinical diagnosis of ASD, Suicidal thoughts and Life transitions, interpersonal 2
older defined by DSM-5 criteria behaviors conflicts
22.98 (6.01) Self-report of a formal ASD SBQ-R total score Loneliness, depression, anxiety, 3
diagnosis (lifetime suicidal ASD symptom severity
ideation, lifetime
suicide plan, lifetime
suicide attempt)
ASD group: Diagnosis of ASD by DSM-IV or Suicide attempts Mood disorders, length of stays at 4
33.7 (12.6) by cutoff score of 26 on AQ- psychiatric hospital and
Non-ASD Japanese version intensive care unit
group: 42.5
(17.0)
18.29 (14.48) Community-based medical Suicide death Method of death 4
diagnosis of ASD
21.47 (9.47) Published case reports in which Suicidal thoughts, Two out of 17 (11.8%) patients 2
Age range: symptoms of autism or pervasive suicidal behaviors reported suicidal thoughts or
9–40 years developmental disorders clearly behaviors
described
Self-harmers: Self-reported autism diagnosis SBQ-R total score, Perceived social support, self- 4
41.5 (13.8) lifetime suicidal harm, anxiety
Non-self- ideation, lifetime
harmers: 44.6 suicide plan, lifetime
(14.3) suicide attempt
41.9 (13.4) A formal diagnosis of autism Suicidal ideation, Thwarted belonging, perceived 4
suicide attempts burden, acquired capability,
depression, anxiety
34.5 (11.2) Formal diagnosis of ASD/AS and Suicide attempts History of depression, autism 2
a score of 26 or higher on the AQ symptomatology severity
41.7 Self-reported diagnosis of ASC SBQ-R total score Thwarted belonging, perceived 4
Age range: from a trained clinician (lifetime suicidal burden, autistic traits, trauma
18–73 years ideation, lifetime
suicide plan, lifetime
suicide attempt)
26.36 (11.37) ASD diagnosis as documented in Suicidal ideation Engagement in activities, family 3
the medical record system or history of depression/anxiety
confirmed by clinical judgement
30.2 (9.8) Suicide deaths, 3
suicide attempts
(continued on next page)
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A.M. Mournet et al. Clinical Psychology Review 99 (2023) 102235

Table 1 (continued )
Authors (Year) Sample size & description Sample age Autism conceptualization STB-related factors Prevalence and/or examined Risk
mean (SD) factors of bias
score

26 autistic adults in a Formal clinical assessment and Two (7.7%) patients died by
psychiatric intensive care diagnosis according to DSM-IV- suicide and one (3.8%) patient
unit TR attempted suicide twice
Richards et al. 245 adults recruited online Median age: 36 Self-reported diagnosis or Suicide attempts Autistic traits 3
(2019) IQR: 19 suspected diagnosis of
Age range: neurodevelopmental conditions,
18–65 years AQ-50
Russell et al. 4959 individuals from the Not available Diagnosis of ASC Suicide attempts, ASC was associated with suicide 2
(2021) Avon Longitudinal Study of suicidal ideation attempts
Parents and Children
Rydén et al. 41 patients seeking 29 (8.21) WAIS-III and further assessment Suicide attempts Borderline personality disorder 3
(2008) treatment for borderline for ASD diagnostic criteria
personality disorder
Shtayermman 10 adolescents and young 19.7 (3.0) Diagnosis of AS Suicidal ideation Victimization 3
(2007) adults with AS recruited
online through snowball
sampling and advertisement
on AS-related websites
Shtayermman 10 adolescents and young 19.7 (3.0) Diagnosis of AS Suicidal ideation 50% of the sample had a 3
(2008) adults with AS recruited clinically significant level of
online through snowball suicidal ideation
sampling and advertisement
on AS-related websites
Strauss et al. 172 trans young people with Age range: Self-reported diagnosis of ASD Suicidal thoughts and Gender identity, access to 2
(2021) ASD 14–25 years from a health professional behaviors gender-affirming care
687 trans young people
without ASD
Takara and Kondo 366 psychiatric outpatients 41.2 (14.3) SCID used to diagnosis subtypes Suicide attempts Suicide attempt method 4
(2014a) of ASD
Takara and Kondo 70 psychiatric autistic 40.4 (14.7) SCID used to diagnosis subtypes Suicide-related ASD group was significantly 4
(2014b) outpatients of ASD behaviors characterized by more episodes
360 psychiatric non-autistic of suicide-related behaviors
outpatients (24% vs. 13%: chi-square = 5.8,
df = 1, P = .019)
Vohra et al. (2016) 25,527 emergency Age range: ICD diagnosis codes Suicidal ideation Adults with ASD had higher rates 3
department visits for autistic 22–64 of suicidal ideation (2.6%) than
adults adults without ASD (0.9%)
Wahlund and 35 male offenders (8 with Age range: Diagnosed according to DSM-IV Suicide attempts 2 out of 8 participants with 2
Kristiansson autism) 15–71 criteria autism had a previous suicide
(2006) attempt
Warrier and 150 autistic individuals Not available Diagnosis by a professional Suicidal behavior Childhood trauma 3
Baron-Cohen 105,488 non-autistic and ideation
(2021) individuals
Recruited from United
Kingdom Biobank
*
AdAS Spectrum = Adult Autism Subthreshold Spectrum; ADI-R = Autism Diagnostic Interview-Revised; ADOS-2 = Autism Diagnostic Observation Schedule,
Second Edition; AS = Asperger’s syndrome; ASC = autism spectrum conditions; ASD = autism spectrum disorders; AQ = Autism Spectrum Quotient; BSS = Beck Scale
for Suicidal Ideation; COVID-19 = coronavirus disease 2019; DSI-SS = Depression Symptom Inventory – Suicidality Subscale; DSM-IV = Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition; EMR = electronic medical record; ICD = International Classification of Diseases; ID = intellectual disability; INQ =
Interpersonal Needs Questionnaire; SBQ-R = Suicide Behaviors Questionnaire-Revised; SCID = Structured Clinical Interview for DSM-IV; SITBI = Self-Injurious
Thoughts and Behaviors Interview; STB = suicidal thoughts and behaviors; WAIS-IV = Wechsler Adult Intelligence Scale, Fourth Edition.

from online platforms in Australia, autistic individuals were signifi­

cantly more likely to have suicidal thoughts and prior suicide attempts
than non-autistic individuals (Strauss et al., 2021). Additionally, two
studies compared the method used to attempt suicide by individuals
with and without autism. Kirby et al. (2019) found that in a study of
suicide deaths in one US state, autistic individuals were significantly less
likely to attempt suicide using firearms, compared to adults in the
general population. In a study of psychiatric outpatients, autistic adults
were most likely to attempt suicide via hanging, compared to non-
autistic adults, where the most prevalent suicidal method was drug
overdose (Takara & Kondo, 2014b).

2.2. Risk and protective factors for STBs among autistic adults

2.2.1. Genomic studies

Fig. 3. Number of included articles per year (1994–2022). Two genomic studies investigated associations between STBs and
diagnosis of autism among adults showing support for a link between the

6
A.M. Mournet et al.
genetics associated with autism and suicidal behaviors and suicide
deaths. In the Avon Longitudinal Study of Parents and Children, an
exploratory genetic epidemiology study, polygenic risk scores for autism
spectrum conditions were associated with suicide attempts (Russell
et al., 2021). An additional study of individuals who had died by suicide
in one US state found that suicide polygenic score elevations were
associated with numerous clinical diagnoses, including autism spectrum
disorder (Docherty et al., 2020).
2.2.2. Mood disorders
Thirty-two articles (73.3%; 33/45) highlighted suicide risk and
protective factors among autistic adults. Many of these studies specif­
ically examined the presence of other mental health disorders (e.g.,
Hirvikoski et al., 2020), with Kato et al. (2013) reporting that among
adults admitted to the hospital due to a suicide attempt, autistic adults
were significantly more likely to also have mood disorders and adjust­
ment disorders. In particular, numerous studies (36.4%; 12/33) high­
lighted the role of depression as a mediator between autism and STBs (e.
g., Costa, Loor, & Steffgen, 2020; Croen et al., 2015; Hand, Benevides, &
Carretta, 2020; Paquette-Smith, Weiss, & Lunsky, 2014; Radoeva, Bal­
linger, Ho, Webb, & Stobbe, 2021). For instance, Cassidy et al. (2014)
found that among individuals presenting to a specialist diagnostic clinic,
those with Asperger syndrome (Asperger’s) and depression were more
likely to endorse suicidal ideation, plans, and attempts, compared to
adults with Asperger’s who did not have depression. Other co-occurring
mental health disorders, such as borderline personality disorder (BPD),
have been linked to suicide attempts among individuals with autism,
within a sample of adults taking part in a BPD treatment program
(Rydén, Rydén, & Hetta, 2008).
Studies that find co-occurrence of mood disorders is a risk factor for
STBs in autism leave open the question of whether STB risk is a result of
the psychopathology itself, the additive effect of being autistic and
having co-occurring mood disorders, or something synergistic about
being autistic and having co-occurring mood disorders. We hypothesize
that it is possibly a synergistic effect for several reasons. For example, it
may be that treatments for mood disorders are not tailored for autistic
populations, making mood disorders especially “risky” among autistic
populations who do not receive the same benefit from treatment as non-
autistic individuals.
2.2.3. Differential exploration of autism symptoms among autistic
populations
Many of the included studies (28.1%; 9/32) also examined the
impact of specific autism symptoms on suicide risk among autistic
adults. Across studies, various autism symptoms and severity of these
symptoms were associated with increased STBs (e.g., Dell’Osso et al.,
2019; Hedley et al., 2021; Paquette-Smith et al., 2014; Richards et al.,
2019; Shtayermman, 2008). For instance, among a sample of autistic
adults recruited through online platforms, those who endorsed suicidal
ideation had significantly higher social communication difficulties and
insistence on sameness, and lower levels of cognitive control compared
to those without suicidal ideation (Hedley, Uljarević, et al., 2021).
Moreover, among adults recruited from Asperger’s and autism advocacy
organizations and websites, those who attempted suicide were more
likely to self-report more severe autism symptomatology (Paquette-
Smith et al., 2014).
2.2.4. Stressors and behaviors
Several stressors and behaviors have also been examined as risk
factors for STBs among autistic adults. Research using the United
Kingdom Biobank has supported the role of trauma, including childhood
trauma, as a mediator between autism diagnosis and a composite score
of STBs (Warrier & Baron-Cohen, 2021). Despite the widespread stress
associated with the COVID-19 pandemic, COVID-19’s early impact was
not associated with suicide risk among autistic adults recruited through
an emailed newsletter (Hedley et al., 2021). Additionally, non-suicidal
7
Clinical Psychology Review 99 (2023) 102235
self-injury significantly predicted STBs among autistic adults (Cassidy,
Bradley, Shaw, & Baron-Cohen, 2018). The impact of additional po­
tential suicide risk factors, including rumination, self-esteem, and
temperament on STBs has also been studied among autistic adults.
Arwert and Sizoo (2020) investigated the impact of rumination and self-
esteem on STBs among autistic adults receiving psychiatric outpatient
care and found that low self-esteem was significantly associated with
presence of suicidal ideation and rumination was significantly associ­
ated with a history of suicide attempts. In another study of psychiatric
outpatients focused on investigating the role of temperament and
character among autistic adults, regression models revealed no signifi­
cant relationship between suicidal ideation and novelty seeking, harm
avoidance, and self-directedness, when the significant influence of
depression was controlled for (Hooijer & Sizoo, 2020).
2.2.5. Healthcare utilization and access
Utilization and access to healthcare services and support were
analyzed in five studies (15.2%; 5/33). In a sample of autistic adults
recruited from an online autism research database, number of unmet
support needs was predictive of a composite score of STBs (Cassidy,
Bradley, Shaw, & Baron-Cohen, 2018). Among a sample of Medicaid-
enrolled autistic adults, utilization of psychiatric healthcare, along
with younger age, White race, and depressive disorders were associated
with greater odds of suicidal ideation and attempts (Hand, Benevides, &
Carretta, 2020). Length of stay at the hospital and in the intensive care
unit due to a suicide attempt was also found to be longer among autistic
patients, compared to non-autistic patients (Kato et al., 2013).
Comparatively, several qualitative studies found that a lack of access to
treatment and social support services is a common antecedent to
thoughts of suicide among two different samples of autistic adults, one
of which recruited from the Cambridge Autism Research Database
(Camm-Crosbie, Bradley, Shaw, Baron-Cohen, & Cassidy, 2019) and the
other from Facebook support groups for autistic adults (Moseley,
Gregory, Smith, Allison, & Baron-Cohen, 2020).
2.3. Social and interpersonal constructs
One of the most common factors examined in relation to suicide risk
among autistic adults was interpersonal variables (42.4%; 14/33 total
studies looking at risk/protective factors). Three of these studies (21.4%;
3/14) focused on the IPTS (Joiner, 2005; Van Orden et al., 2010) con­
structs of perceived burden and thwarted belonging. Other interpersonal
variables include interpersonal conflict and bullying.
Work by Pelton et al. (2020a) of adults recruited through research
databases found that autistic adults reported stronger feelings of
perceived burden and thwarted belonging than non-autistic adults.
Moreover, autistic adults who reported perceived burden and thwarted
belonging were more likely to endorse past suicide attempts, compared
to autistic adults who did not endorse perceived burden and thwarted
belonging (Pelton et al., 2020a). Research by Dow et al. (2021) found
that among a community sample of autistic adults recruited through six
universities, thwarted belonging and perceived burden were associated
with current suicidal ideation. Perceived burden was also associated
with past suicide attempts, though thwarted belonging was not associ­
ated with past suicide attempts (Dow et al., 2021). Similarly, Moseley
et al. (2022) reported that perceived burden was associated with both
past suicidal ideation and past suicide attempts, whereas thwarted
belonging was not associated with either suicide-related outcome.
Several studies also investigated the role of loneliness as a suicide
risk factor among autistic adults. Among a cross-sectional online sample
of autistic adults, loneliness and reporting fewer friends were signifi­
cantly associated with lifetime suicidal behavior (Jackson, Hart, Brown,
& Volkmar, 2018). In a national study of autistic adults recruited
through support groups, universities, and social media, social support
satisfaction and loneliness predicted suicidal thoughts but was mediated
by depression (Hedley, Uljarević, Wilmot, Richdale, & Dissanayake,
A.M. Mournet et al.
2018). Hedley and colleagues further found that on a cross-sectional
level, depressive symptoms, loneliness, and thoughts of self-harm or
being better off dead were significantly correlated, and that depressive
symptoms mediated the relationship between loneliness and thoughts of
self-harm or being better off dead (Hedley, Uljarević, Foley, Richdale, &
Trollor, 2018).
Interpersonal conflicts have also been found to be a common pre­
cursor to STBs among a sample of 16 autistic adults presenting to the
psychiatric emergency department (Jachyra et al., 2021). Relatedly,
among a sample of young adults with Asperger’s recruited online
through snowball sampling and advertisement on AS-related websites,
overt and relational victimization was highly endorsed, along with 50%
of the sample endorsing clinically significant levels of suicidal ideation
and 20% of the sample meeting criteria for a diagnosis of major
depressive disorder (Shtayermman, 2007).
While most studies have found social connection to be associated
with STBs among this population, at least two studies failed to detect
such dynamics. Moseley et al. (2020) found no significant relationship
between STBs and social support among autistic adults recruited
through a research database and social media. An additional study found
that social support, operationalized as appraisal and belonging, was not
associated with suicidal ideation, though the perceived availability of
tangible support (i.e. “If I were sick, I could easily find someone to help
me with my daily chores”) was indirectly associated with suicidal
ideation, mediated by depressive symptoms (Hedley, Uljarević, Wilmot,
Richdale, & Dissanayake, 2017).
3. Discussion
Since 2006, there has been a clear upward trend in the publication of
research investigating STBs among autistic adults. Prior to this point, the
existing literature was largely made up of case studies, as evidenced by
the 23 case studies detected in the initial search. With limited studies
reporting on the prevalence rates of suicidal ideation among autistic
adults, it is perhaps unsurprising that there is considerable variability in
the reported rates of STBs among samples of autistic people. Even by the
lowest reported rate of suicidal ideation (16%; Bradley et al., 2021), it is
apparent that autistic adults are a group with markedly elevated risk for
suicide. With increasing studies reporting on the prevalence of STBs and
the associated risk and protective factors among this population, there
are also many promising areas for future research. In the sections below,
we summarize two key content areas: exploring social and interpersonal
constructs and better understanding the role of depressive symptoms in
autism. We then conclude by discussing needed future directions in the
study of autism and suicide.
3.1. Social and interpersonal constructs
Social connectedness, the perception that one is close and connected
to other people, is a well-established protective factor against suicide
risk in the general population (Chang, Chan, & Yip, 2017; Marraccini &
Brier, 2017), suggesting that the association observed in studies of
autistic adults warrant attention. Moreover, one of the leading theories
of suicide, the IPTS, centers around the impact of poor social connection
on suicide risk. When considering the numerous studies that examined
interpersonal constructs as factors in the occurrence of STBs among
autistic adults, results suggest that the IPTS may provide a useful
framework for understanding the suicidal ideation and behavior among
this population (Dow et al., 2021; Pelton et al., 2020a), though further
investigation of additional factors, including depressive symptoms, may
further illuminate the relevance of the IPTS for this population.
3.1.1. Social motivation theory of autism and its lack of applicability to
STBs within autism
The role of increasing social connection to reduce suicide risk may be
particularly relevant among autistic individuals, considering that
8
Clinical Psychology Review 99 (2023) 102235
deficits in social communication skills and developing and maintaining
relationships are considered core features of autism spectrum disorders
(American Psychiatric Association, 2013). When discussing social
connection in autism, it is important to discuss the social motivation
theory. Although not yet applied to suicide within autism, the theory has
received some traction in related areas of autism but is largely not
support by the literature. Thus, it is important to discuss this theory to
provide additional information that it likely does not explain suicide risk
in autism. The social motivation theory of autism poses that, beyond
perception, autism represents an “extreme case of diminished social
motivation and, as such, provides a powerful model to understand
humans’ intrinsic drive to seek acceptance and avoid rejection” (Che­
vallier, Kohls, Troiani, Brodkin, & Schultz, 2012, p. 231). Contrary to
this theory, investigation of the objective connections among adults has
shown that autistic adults had similar amounts of social groups to non-
autistic adults and that the majority of autistic adults (75.5%) report
feelings of social identification with at least one group (Maitland, Rho­
des, O’Hare, & Stewart, 2021). Moreover, this theory fails to acknowl­
edge that many autistic individuals are highly motivated to connect, yet
often face social rejection. In other words, autistic adults cannot be
assumed to have fewer connections – or a reduced desire to have social
connections. To paint an even clearer picture of the motivation to con­
nect with others, beyond characterizing the levels of social motivation,
researchers may consider studying the concordance between social
motivation, perceived connection with others (i.e., thwarted belonging
and perceived burden), and tangible connection with others using social
network scales (e.g., Lubben Social Network Scale; Lubben et al., 2006).
In doing so, potential discrepancies in desired levels of social connection
and existing connections (e.g., low levels of thwarted belonging and few
social connections), may reveal that improving social connection is a
useful protective factor against suicide risk for autistic adults.
While research is needed to investigate the impact of social moti­
vation, studies should not lose sight of the potential distinction between
pleasure derived from social interactions versus the actual desire and
motivation to connect. In one study focusing on the social motivation
theory of autism, researchers “directly measure social motivation by
looking at responses to a questionnaire assessing self-reported pleasure
in social and non social situations” (Chevallier, Grèzes, Molesworth,
Berthoz, & Happé, 2012, p. 1504). It is not entirely clear that self-
reported pleasure in social situations equates to social motivation.
While the work of Chevallier, Grèzes, et al. (2012) goes beyond prior
research on social motivation among individuals with autism that pre­
viously studied only cognitive domains to assess the self-reported
motivation for social interaction, future studies should go a step
further to directly assess motivation, desire, and value related to social
connection, beyond the derived pleasure. Moreover, investigation into
what “social connection” means to autistic people would help to further
elucidate that impact, meaning, and value that social connection has for
this community. Better understanding is needed to inform ways to best
assess this construct to explore social connection as a protective factor in
suicide research.
3.1.2. Other relevant social factors
There are a variety of factors that are related to social constructs in
autism but have not yet been studied as predictors of suicide risk. For
example, autistic burnout – the chronic exhaustion, loss of skills, and
reduced tolerance to stimuli that result from life stressors and barriers to
accessing supports that create an inability to obtain relief (Raymaker
et al., 2020). Raymaker et al. (2020) interviewed 19 autistic adults on
their experiences with autistic burnout. Participants described social
support and unmasking, or doing things in “an autistic way,” as asso­
ciated with recovery from autistic burnout (Raymaker et al., 2020).
Moreover, Raymaker et al. (2020) suggest that autistic burnout educa­
tion may be a beneficial component of suicide prevention programs. This
is in line with existing research on camouflaging, behavioral adaptations
used to mask autism symptoms, in which camouflaging was associated
A.M. Mournet et al.
with increased thwarted belonging and suicidal behavior (Cassidy et al.,
2020).
Given the potential impact of autistic burnout and camouflaging on
suicide risk, future research may benefit from an increased focus on who
autistic individuals are motivated to connect with and report connec­
tions with. Namely, this “who” factor may explain some of the dis­
crepancies in the role of social connection as a protective factor against
suicide. Connections with other autistic adults or other people where
camouflaging is not necessary may increase the value of social connec­
tion. Relatedly, research on the social interaction mismatch hypothesis
has suggested that having helpful social connections is relevant both to
the individual themselves as well as to aspects of interpersonal similarity
(Redcay & Schilbach, 2019). This hypothesis has been applied to autistic
individuals, with findings that interpersonal similarity among autistic
individuals is predictive of the quality of friendships (Bolis, Lahnakoski,
Seidel, Tamm, & Schilbach, 2021). Future research investigating the
impact of social connection for autistic individuals should consider the
role of interpersonal similarity. Moreover, victimization and bullying
are a concern for autistic individuals, even among adults (Weiss &
Fardella, 2018), and represent a potential reason to engage in acts of
camouflaging. Shtayermman (2008) work highlighting the cooccur­
rence of victimization and suicide among autistic young adults supports
the need for studies to assess both positive social connectedness, as well
as victimization experiences, both past and present, among autistic
adults.
3.2. Depressive symptoms
Increasing research studies have investigated the impact of inter­
personal factors on suicide risk among autistic adults, though various
questions remain. A particularly salient area requiring further investi­
gation is the role of depression as a tertiary factor in relation to social
connection and suicide risk among autistic adults. Even in the general
population, increased social connection is associated with lower levels
of STBs and depressive symptoms (Szanto et al., 2012), yet few studies
have investigated whether depressive symptoms serve as a mediator or a
moderator for the relationship between social connection and suicide
risk. It may also be that depression leads to suicide risk and is mediated
or moderated by social connection. Investigation into the complexity of
the associations between these factors has the potential to elucidate the
impact of social connection on specific mental health conditions.
Moreover, with limited studies on this matter among autistic and non-
autistic individuals, comparison studies to understand how the impact
of social connection on depression and suicide might differ based on a
diagnosis of autism would further help to clarify potential areas for in­
terventions aimed at supporting desired levels of social connection.
Beyond the link between interpersonal factors and depressive
symptoms, depressive symptoms was one of the most frequently exam­
ined variable across the included articles, appearing in 11 studies. In
many instances, depression appeared to largely explain the association
between STBs and other potential risk factors against suicide (e.g.,
Hedley, Uljarević, Wilmot, et al., 2018). With numerous studies sup­
porting the role of depression as a mediator, future studies examining
suicide risk among this population ought to continue to include
depressive symptoms as a variable to ensure the ability to investigate the
extent to which any significant relationships detected can be better
explained by the presence of depressive symptoms, building upon
existing research on how autistic individuals are at greater risk for
depression (Rai et al., 2018).
Importantly studies should also seek to address measurement issues
that may lead to confounding, wherein depression measures include
items related to suicide. There is symptom overlap between depressive
disorders and ASD, such as flat or constricted affect, social withdrawal,
and reduced eye contact. This creates difficulty, as ASD symptoms may
be captured as depressive symptoms (Chandrasekhar & Sikich, 2015).
Further, autistic individuals can experience difficulty in interpreting
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Clinical Psychology Review 99 (2023) 102235
their own internal emotional experience, leading to under- or misreport
of their emotional state when providing self-report (Kinnaird, Stewart, &
Tchanturia, 2019). More practically, autistic individuals might interpret
questions (e.g., I’ve been feeling down; I’ve been feeling blue) literally
(Happé, 1995). Each of these factors limit the validity of traditional
depression instruments in autistic people (Cassidy, Bradley, Bowen,
Wigham, & Rodgers, 2018) and should be directly considered as in­
struments are updated or developed.
3.3. Future research directions
3.3.1. Additional work on protective factors
It is striking that only 4.5% of studies reviewed (2/44) focused on
protective factors against suicide risk (Hedley et al., 2017; Moseley
et al., 2020). This lack of studies on factors that are negatively associated
with suicide risk or that buffer other risk factors highlights a consider­
able gap in the existing research on STB among autistic individuals.
Future research should continue to consider whether social connection
is a protective factor against depression leading to suicide risk.
3.3.2. Theory-driven research
While a significant portion of studies emphasized factors from the
IPTS, such as thwarted belonging and perceived burden, key constructs
from other theories focused on understanding suicidal thoughts and
behaviors have yet to be investigated among autistic adults. Further
research is needed that considers whether other major theories, such as
the more contemporary 3ST and IMV theories of suicide (Klonsky et al.,
2021; O’Connor & Kirtley, 2018) are applicable to autistic populations.
3.3.3. Distinction between autistic traits and autism diagnoses
A total of 18 studies in the initial literature search (10.2%; 18/176)
were excluded solely as a result of the sample focusing on individuals
with autistic traits, as opposed to individuals with a diagnosis of autism
(Beck, Lundwall, Gabrielsen, Cox, & South, 2020; Cassidy, Gould, et al.,
2020; Chabrol & Raynal, 2018; Dell’Osso et al., 2019; Dell’Osso et al.,
2019; Dell’Osso et al., 2019; Dell’Osso et al., 2018; Gallyer, Stanley,
Day, & Joiner, 2020; Hochard, Pendrous, Mari, & Flynn, 2020; Pelton &
Cassidy, 2017; Raynal, Melioli, & Chabrol, 2019; Raynal, Melioli,
Goutaudier, & Chabrol, 2016; Sampson et al., 2020; South et al., 2020;
Stanley et al., 2021; Umeda et al., 2019; Upthegrove et al., 2018; Zhou,
Wang, & Chasson, 2018). In these studies, autistic traits are defined by
scores on autism screening or diagnostic questionnaires comprising
items regarding social skills and other behavioral difficulties or prefer­
ences. Importantly, however, so-called “autistic traits,” or “autism
symptoms” on these instruments do not always equate to a diagnosis of
autism (Lord & Bishop, 2021). Indeed, adults with other psychiatric
diagnoses often have elevated scores reflecting difficulties attributable
to those clinical conditions (e.g., social anxiety) that affect social reci­
procity or behavioral flexibility (e.g., South & Rodgers, 2017), thereby
motivating the decision to exclude these studies in the current system­
atic review. To further the understanding of STBs within the context of
autism, it is essential that suicide prevention researchers more clearly
investigate and report whether participants have an established autism
diagnosis (Bal & Lounds Taylor, 2019).
3.3.4. Measurement of STBs
This systematic review revealed numerous areas for future research
with regards to the measurement of STBs among autistic individuals. In
particular, non-suicidal self-injurious behaviors are sometimes observed
in autism but are not necessarily always comparable to the non-suicidal
self-injury exhibited in the general population. Notably, Cassidy, Brad­
ley, Shaw, and Baron-Cohen (2018) observed that non-suicidal self-
injury significantly predicted STBs among autistic adults and high­
lighted the potential differences in the phenotype of non-suicidal self-
injury among autistic adults compared to non-autistic adults. Future
research on the topic of self-injury among autistic adults should strive to
A.M. Mournet et al.
continue to clearly differentiate between suicidal self-injury, non-sui­
cidal self-injury, as well as self-injury that is observed in association with
autism when reporting findings on this topic. Relatedly, numerous
studies utilized the Suicidal Behaviors Questionnaire – Revised (SBQ-R;
Osman et al., 2001) as a measurement of STBs (e.g., Bradley et al., 2021;
Costa et al., 2020; Jackson et al., 2018; Pelton et al., 2020a). While the
SBQ-R is advantageous in that it assesses four dimensions of STBs, when
researchers only report total scores of the SBQ-R, it is difficulty to piece
apart how risk and protective factors relate specifically to suicidal
thoughts versus suicidal behaviors.
Also on a methodological level, studying how these risk and pro­
tective factors, as well as suicide risk, change over short periods of time
may advance the understanding of whether these factors are proximal or
distal and states versus traits. Previous research has shown that suicidal
ideation and numerous risk factors for suicide fluctuate rapidly, even
within hours and minutes (Kleiman et al., 2017). To the authors’
knowledge, no study to date has examined fluctuations in STBs and
associated risk and protective factors among autistic individuals. Future
research would benefit from utilizing ecological momentary assessment
(EMA) to obtain a more finely grained and accurate understanding of the
potentially dynamic nature of risk and protective factors against suicide
risk among autistic adults. Recent research by Dallman, Bailliard, and
Harrop (2022) serves as a strong example of how leveraging the use of
EMA among autistic individuals allows for greater insight into the
mental health of this population. Specifically, researchers used EMA to
demonstrate that negative affect was predicted by momentary quality of
social interaction and enjoyment of the current activity (Dallman et al.,
2022).
Finally, suicidal thoughts and behaviors have been shown to vary
across age groups, particularly with regards to the factors that are
associated with these outcomes (Mournet et al., 2021). Despite this,
research studies have continued to produce papers that measure suicidal
thoughts and behaviors across broad developmental periods. When
publishing studies about suicide risk, particularly among autistic in­
dividuals where developmental abilities may have considerable range,
researchers should avoid reporting findings that mix developmental
groups.
3.3.5. Adaptation of existing measures
As a result of minimal studies focused on adapting existing measures
for use among autistic adults, a post-hoc decision was made to exclude
these studies. However, in order to address the high prevalence of sui­
cide risk among autistic adults, it is important to be able to accurately
assess and understand suicide risk. The systematic exclusion of autistic
individuals from studies seeking to validate suicide risk measures poses
serious concerns regarding the validity of these tools for this population,
necessitating investigation into the accuracy of measures for use with
autistic individuals. Only two studies have begun to adapt existing
measures of STBs for autistic adults. In particular, the SBQ-R, was
completed by a sample of adults with autism and a subsample provided
feedback on the questionnaire (Cassidy et al., 2020). The SBQ-R items
surrounding communicating one’s suicidal intent and one’s likelihood of
attempting suicide in the future revealed metric non-invariance of the
SBQ-R and the items were not interpreted as intended, suggesting a need
for adaptation of this tool, and others, to better assess STBs among
autistic adults. Similarly, the Interpersonal Needs Questionnaire (INQ;
Van Orden, Cukrowicz, Witte, & Joiner, 2012), which is the self-report
scale developed to assess the constructs of the IPTS, had different
measurement properties among autistic people compared to those
without autism (Pelton et al., 2020b). Consequently, scores on the INQ
may not be able to be meaningfully interpreted for autistic adults in
relation to those without autism, creating a need for investigation into
how to improve the assessment of perceived burden and belonging
among autistic adults.
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Clinical Psychology Review 99 (2023) 102235
3.3.6. Treatment
In addition to a pressing need to investigate the efficacy of existing
measures of STBs for use among autistic adults, adaptation of existing
treatments for STBs is likely to also be necessary. Preliminary evidence
from a study of seven autistic adults found that dialectical behavioral
therapy (DBT), a well-documented treatment for STBs among the gen­
eral population (Linehan et al., 2006), was feasible, highly acceptable,
and effective for autistic adults who endorsed self-harm and/or suicidal
behaviors (Bemmouna, Coutelle, Weibel, & Weiner, 2021). Increasing
studies have sought to modify cognitive behavioral therapy for social
anxiety and social functioning among autistic young adults (Bemmer
et al., 2021). Building upon this research, future research should seek to
continue to investigate the need for modifications to existing suicide risk
treatments to be optimized for autistic adults. Concurrently, it will be
necessary to investigate ways to increase clinicians’ use of suicide
treatment approaches, such as safety planning, for autistic individuals
(Jager-Hyman, Maddox, Crabbe, & Mandell, 2020).
3.4. Limitations
This review should be interpreted with consideration for the
following limitations. We opted to exclude case studies in order to focus
our review on larger scales studies that had a greater ability to report
prevalence rates and suicide risk and protective factors. This resulted in
the exclusion of 25 case studies. Future research may benefit from a
systematic review or meta-analysis of case studies of autistic individuals
who endorse STBs, thereby building upon the early work of Lainhart and
Folstein (1994). Additionally, most of these studies are comprised of
self-reporting adults, meaning that adults with lower IQs are likely un­
derrepresented in the current systematic review. A considerable level of
variability also existed with regards to study type (e.g., online survey
studies reliant on questionnaires with no contact versus studies on an
inpatient unit with careful assessment of study constructs), which may
introduce a level of noise and unclarity regarding aspects such as effect
sizes and mediations versus moderations. To help address this, when
reporting mixed findings or contextualizing one’s own results within
their sampling approach, it is necessary to clearly describe these
features.
4. Conclusions
Autistic adults represent a high-risk group for STBs. Interpersonal
constructs were found to be highly studied factor in this review,
underscoring the potential of social connectedness to be a particularly
impactful protective factor for autistic individuals. Importantly,
depressive symptoms also appear to play important roles in the presence
of STBs, highlighting a need to continue to include the assessment of
these variables in future studies. As researchers continue to explore STBs
within the context of autism in adulthood, it will be necessary to
addressing the overreliance on autistic symptoms instead of autism di­
agnoses, measurement issues with regards to STBs, and the need for
treatment adaptations. Moreover, research that leverages EMA ap­
proaches may be particularly well equipped to clarify the fluctuation of
certain factors and identify modifiable variables that can be beneficial
targets for treatment.
Role of funding sources
The authors have no funding sources to disclose.
Contributors
All authors designed the study. Authors A.M.M, E.M.K, and V.H.B.
conceptualized the study. Authors A.M.M. and E.M.K conducted the
literature searches. Author A.M.M. wrote the original draft of the
manuscript and authors E.W., V. H.B., and E.M.K. reviewed and edited
A.M. Mournet et al. Clinical Psychology Review 99 (2023) 102235

and all authors have approved the final manuscript. Chang, Q., Chan, C. H., & Yip, P. (2017). A meta-analytic review on social relationships
and suicidal ideation among older adults. Social Science & Medicine, 191(1982),
65–76. https://doi.org/10.1016/j.socscimed.2017.09.003
Chen, M. H., Pan, T. L., Lan, W. H., Hsu, J. W., Huang, K. L., Su, T. P., … Bai, Y. M.
Declaration of Competing Interest (2017). Risk of suicide attempts among adolescents and young adults with autism
spectrum disorder: A nationwide longitudinal follow-up study. The Journal of Clinical
The authors have no conflicts of interest to disclose. Psychiatry, 78(9), e1174–e1179. https://doi.org/10.4088/JCP.16m11100
Chevallier, C., Grèzes, J., Molesworth, C., Berthoz, S., & Happé, F. (2012). Brief report:
Selective social anhedonia in high functioning autism. Journal of Autism and
Data availability Developmental Disorders, 42(7), 1504–1509. https://doi.org/10.1007/s10803-011-
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Chevallier, C., Kohls, G., Troiani, V., Brodkin, E. S., & Schultz, R. T. (2012). The social
No data was used for the research described in the article.
motivation theory of autism. Trends in Cognitive Sciences, 16(4), 231–239. https://
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