Autism, Self-Harm, and Co-Occurring Psychiatric Diagnoses

In The Politics of Autism, I write about the many challenges facing people on the spectrum.  Among many other things, they are at high risk for suicide. (In July, the United States transitioned from 10-digit National Suicide Prevention Lifeline to 988 – an easy-to-remember three-digit number for 24/7 crisis care. "

Meng-Chuan Lai et al., "Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada," JAMA Netw Open. 2023;6(8):e2327415. doi:10.1001/jamanetworkopen.2023.27415

Key Points

Question What are the sex-stratified rates of self-harm events and suicide death among autistic individuals vs nonautistic individuals and the associated sociodemographic and clinical risk factors?

Findings In this cohort study including 379 630 individuals regarding self-harm findings and 334 690 individuals regarding suicide death findings in Ontario, Canada, autistic females had an 83% increased risk and autistic males had a 47% increased risk of self-harm compared with nonautistic individuals, when accounting for neighborhood income and rurality, intellectual disabilities, and psychiatric diagnoses. The crude hazard ratio showed that autistic females had a 98% increased risk and autistic males had a 34% increased risk of suicide death, but these increases were associated with psychiatric diagnoses.

Meaning This study suggests that psychiatric diagnoses were significantly associated with risks of self-harm and especially suicide among autistic females and males.

Suicidal Ideation

In The Politics of Autism, I write:

Many analyses of autism speak as if it were only a childhood ailment and assume that parents are the main stakeholders. But most children with autism grow up to be adults with autism, and they suffer uniquely high levels of social isolation. Almost 40 percent of youth with an autism spectrum disorder never get together with friends, and 50 percent of never receive phone calls from friends. These figures are higher than for peers with intellectual disability, emotional disturbance, or learning disability. When school ends, many adults with autism have grim prospects. Though evidence is sparse, it seems that most do not find full-time jobs. Compared with other people their age, they have higher rates of depression, anxiety, bipolar disorder, and suicide attempts.

At Autism,  Paige E Cervantes, Derek S Brown, and Sarah M Horwitz have an article titled "Suicidal ideation and intentional self-inflicted injury in autism spectrum disorder and intellectual disability: An examination of trends in youth emergency department visits in the United States from 2006 to 2014."  The lay abstract:

Youth suicide is a major problem in the United States and globally, but little is known about suicide risk in autistic youth and youth with intellectual disability specifically. Using data from the National Emergency Department Sample, which is the largest database of emergency department visits in the United States, we found that emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis were more common in autistic youth and youth with intellectual disability than in youth without these diagnoses (i.e. the comparison group). This was true when examining both suicidal ideation diagnoses and intentional self-inflicted injury diagnoses at emergency department visits. In addition, the number of emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis increased more from 2006 to 2014 in autistic youth and youth with intellectual disability compared with the comparison group. We also found both similarities and differences when examining factors, such as age, sex, and co-occurring mental health conditions, related to emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis across groups that may be helpful for understanding suicide risk. It is urgent that we improve our understanding, assessment, and treatment of suicidality and self-harm in these groups through more research and clinical efforts.

Suicide and Self-Harm

In The Politics of Autism, I write:

Many analyses of autism speak as if it were only a childhood ailment and assume that parents are the main stakeholders. But most children with autism grow up to be adults with autism, and they suffer uniquely high levels of social isolation. Almost 40 percent of youth with an autism spectrum disorder never get together with friends, and 50 percent of never receive phone calls from friends. These figures are higher than for peers with intellectual disability, emotional disturbance, or learning disability. When school ends, many adults with autism have grim prospects. Though evidence is sparse, it seems that most do not find full-time jobs. Compared with other people their age, they have higher rates of depression, anxiety, bipolar disorder, and suicide attempts.

A release from  Columbia University Mailman School of Public Health:

People with autism spectrum disorder (ASD) are at substantially increased risk of self-injury and suicide, according to a study by researchers at Columbia University Mailman School of Public Health and Columbia College of Physicians and Surgeons. They found that odds of self-harm in people with autism spectrum disorder were over three times that of people without ASD. Elevated odds of self-harm existed in both children and adults with ASD, though there were slightly higher odds in adults. The findings are published in JAMA Network Open.

It is estimated that 5,437,988 U.S. adults (2 percent) have autism. In children, prevalence estimates have increased over the past several decades due in part to improved awareness, changes in documentation, and the identification of milder cases.

“The findings from our systematic review and meta-analysis underscore the need for targeted interventions to reduce the risk of self-harm in people with autism,” said Ashley Blanchard, MD, MS, assistant professor of emergency medicine at the Vagelos College of Physicians and Surgeons. “Among the myriad of health problems facing people with ASD is the excess risk of injury morbidity and mortality. The emergency department presents a unique clinical setting for interventions to reduce self-harm and other injuries in people with autism.”

The researchers used PubMed, Embase, CINAHL, PsychInfo, Web of Science databases from 1999 through June of 2020 to identify studies on the relationship between ASD and self-injurious behavior and suicide. They identified 31 studies with a wide range of ages and self-harm outcomes. Twenty-nine showed statistically significant positive associations between ASD and self-harm, and that people with ASD were at similarly increased risk of self-injury behavior and suicide.


According to the researchers, several factors may explain the excess risk of self-harm associated with ASD. The prevalence of self-injurious behavior, such as hand-hitting, self-cutting, and hair pulling, is as high as 42 percent in the autism population. Estimates also show that 28 percent of people with ASD have co-occurring attention deficit hyperactivity disorder, 20 percent have co-occurring anxiety disorders, and 11 percent have co-occurring depressive disorders. There is also a known link between self-injury and suicide.

“Our findings are of public health importance in light of the continuing increase in the reported prevalence of autism and the high prevalence of self-injurious behavior in this population—especially relevant during a period of heightened rates of depression, anxiety, and suicide associated with the COVID-19 pandemic,” said study senior author Guohua Li, MD, DrPH, professor of epidemiology at the Columbia Mailman School, professor of anesthesiology at the Vagelos College of Physicians and Surgeons. “Further research should aim to determine the impact of co-occurring diagnoses, develop injury surveillance systems for the autism population, and implement effective prevention strategies to ensure the safety and well-being of people with ASD.”

Co-authors include Stanford Chihuri, Columbia College of Physicians and Surgeons; and Carolyn DiGuiseppi, University of Colorado Anschutz Medical Campus.

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (grant HD098522).