Joaquín Díaz Atienza
Introduction
In this review (1), the authors justify their literature review based on the significant role suicide plays in young people between the ages of 10 and 24 and the scarcity of research on patients with Autism Spectrum Disorder (ASD). They believe that suicidal behavior in patients with ASD is underrepresented, despite being a significant problem in this population. They attribute this to the prevalence of non-suicidal self-harm in this population, which is quite common.
They then outline the risk factors found in the literature. These include: low self-esteem, difficulties in interpersonal relationships, feelings of social isolation, problems in relationships with parents, and a breakdown in peer relationships.
The objectives of the systematic review are to contribute significantly to updating publications on suicidal behavior in adolescents and young adults with TED and, as specific objectives, to detect the prevalence of these behaviors, as well as possible risk and protective factors.
Methodology
Through a search of a broad database and a wide variety of keywords, 195 articles were identified as potential candidates. After excluding those that did not meet the inclusion criteria, 15 articles remained. The exclusion criteria were: stereotyped self-harm (n=71 articles), suicidal behavior not being the focus of the study (n=28), unrelated topics (n=25), other mental health problems (n=22), target population not being patients with ASD (n=18), explanatory texts (n=11), texts in languages other than English (n=3), and full text not available (n=3). Of these 15 articles, 10 more were excluded because they did not describe the inclusion criteria (n=7), used the same sample for other studies (n=2), or contained text in other languages (n=2). Finally, 4 articles were selected. The findings were considered in terms of prevalence, risk factors, and the association between ASD and suicidality.
Prevalence
In one of the articles, 5 out of 10 patients presented with suicidal ideation, although the questionnaire used was not validated (Shtayerman, 2007). The study by Mandell et al. (2005) investigated suicidal ideation and suicide attempts in a cohort of 182 individuals with ASD and a history of physical and sexual abuse. They found this problem in 31,6% of the patients and in 40% of the sexual abuse victims. Mikami et al. (2009), in a sample of 90 patients hospitalized for self-harm and suicidal ideation, found that at least 13% had been diagnosed with Asperger's syndrome (AS) or PDD-NOS. The prevalence was estimated to be between 7% and 42%.
Risk factors also found in populations with typical development
Age: It is similar to the population with typical development (between 12 and 20 years).
Gender: Although the rate is higher in men, it is suspected that it may be similar in men and women.
psychiatric disordersSeveral disorders have been found, especially mood and anxiety disorders.
Physical and sexual abuseSexual abuse is identified as a risk factor. Regression studies have not found a relationship between physical abuse and suicidal behavior.
Bullying or harassmentAlthough some correlational studies do not find a significant relationship, it should be noted that the samples are small and that it has not been specifically studied.
Specific risk factors in the population with ASD
An association has been found between suicidal behavior and patients with ASD without severe intellectual disabilities compared to those with such disabilities. Similarly, having an ASD itself appears to be a risk factor due to interpersonal problems, difficulties in problem-solving, social isolation, and impulsivity, although there is no empirical evidence. This is more prevalent among patients with less severe cognitive impairment.
Discussion
The authors make the following observations:
1. Suicidal behavior is a major problem in young people with ASD and they present characteristics similar to young people with typical development.
2. The 12,8% diagnosis rate appears to be underrepresented in relation to the general population.
3. Some authors recommend considering the possibility of ASD in patients treated for suicidal behavior, especially in men.
4. Both psychiatric problems and sexual abuse have been identified as risk factors. Physical abuse is less significant.
5. Severity in communication, social interaction and flexibility problems appears to be a moderate risk factor.
Limitations
The authors state the following: small sample size, diagnoses have been accepted without sufficient validation, most research is limited to a single diagnosis: Asperger's syndrome, some studies do not report on IQ, and some studies do not operationalize what is understood by suicidal behavior.
COMMENT
We highlight the following positive aspects:
1. The fact of addressing, with an acceptable methodology, a health problem that is important and that, until now, seems quite neglected.
2. The literature search has been carried out extensively and uses inclusion and exclusion criteria that are quite appropriate for the study objective.
3. It is the first empirical approach to detecting risk and protective factors in this field.
4. It can be the incentive for other researchers to become aware of this problem.
Limitations:
1. Due to exclusion criteria (e.g., the language used), information has been lost and is not included in the review.
2. I believe it is excessive to speak of prevalence or risk factors with excessively small samples that were not designed for that purpose. Therefore, I believe it is an exaggerated claim.
3. In this sense, although the assertion that physical abuse is not associated with suicidal behavior cannot be categorically stated since the design does not allow this assertion.
(1) Geraldine Hannon, Emily Taylor. Suicidal behavior in adolescents and young adults with ASD: Findings from a systematic review. Clinical Psychology Review 33 (2013) 1197-1204. DOI: 10.1016/j.cpr.2013.10.003
