What Do We Know About Suicidality in Autism Spectrum Disorders? A Systematic Review Magali Segers and Jennine Rawana Suicidality is a common and concerning issue across development, and there is a plethora of research on this topic among typically developing children and youth. Very little is known, however, about the nature of suicidality among individuals with autism spectrum disorders (ASDs). The purpose of the current study was to undertake a systematic literature review to assess the current state of the research literature to examine the prevalence of suicidality among individuals with ASD, related demographic and clinical profiles, and associated risk and protective factors. A literature search using key terms related to suicidality and ASD yielded 10 topical studies that were evaluated for the study objectives. Suicidality was present in 10.9–50% of the ASD samples identified in the systematic review. Further, several large-scale studies found that individuals with ASD comprised 7.3–15% of suicidal populations, a substantial subgroup. Risk factors were identified and included peer victimization, behavioral problems, being Black or Hispanic, being male, lower socioeconomic status, and lower level of education. Only one study reported on protective factors, and this is identified as a significant gap in the literature. Several methodological weaknesses were present in the current literature, such as lack of appropriate comparison groups and little to no use of empirically validated measures for ASD diagnosis and suicide assessment. Additional research is necessary to understand better how this unique population experiences and expresses suicidal tendencies. Recommendations for future research are discussed. Autism Res 2014, 7: 507–521. © 2014 International Society for Autism Research, Wiley Periodicals, Inc. Keywords: autism spectrum disorders; suicide; suicidality; prevalence; risk factors; protective factors Introduction Autism spectrum disorders (ASD) are common neuro- developmental disorders characterized by persistent defi- cits in social communication and social interaction and restricted, repetitive patterns of behavior, interest, and activities [American Psychiatric Association, 2013]. The most current estimate for prevalence rates of ASD is 1 in 94 children in Canada (Ouellette-Kuntz et al., 2012) and 1 in 88 in the United States [Centers for Disease Control and Prevention, 2012]. Changes in societal awareness and diagnostic guidelines and practices have highlighted the importance of increasing our understanding of the com- plexities of the disorder. It is increasingly important for clinicians and researchers alike to be aware of the clinical and mental health issues associated with ASD and how they may present differently from typical development. Indeed, the most severe and life-threatening mental health issues are behaviors related to suicidality [Hawton, Saunders, & O’Connor, 2012]. As understanding and awareness of ASD continues to grow, it is critical to examine how suicidal thoughts and behaviors are expressed among individuals with this unique clinical profile. High rates of comorbidity with a range of psychiatric disorders are seen in ASD, particularly with mood and anxiety disorders [Ghaziuddin & Greden, 1998; Hedley & Young, 2006; Munesue et al., 2008]. The connection between mood disorders and suicidal behaviors in typical development is relatively well understood and well researched [Kasper, Schindler, & Neumeister, 1996; Rao, Weissman, Martin, & Hammond, 1993]; however, we know very little about suicidal behaviors in ASD. Con- sidering the high rates of mood and anxiety disorders in ASD [Strang et al., 2012; White, Oswald, Ollendick, & Scahill, 2009] and the established link between depres- sive symptoms such as hopelessness and suicidal behav- iors in typical development [Saltz & Marsh, 1990], it is a critical next step to examine this link in ASD. In the current article, a very broad definition of suicidality was adopted and included ideation (e.g., thoughts of death, thoughts of harming oneself, planning a suicide), self- harm behaviors (e.g., cutting, burning), attempts (e.g., drug overdose, poisoning, jumping), and completed suicide. Suicidality in ASD needs to be examined sepa- rately from typical development to appreciate the complex interplay of ASD-specific traits on factors con- tributing to the onset and recurrence of suicidality. Indi- From the Department of Psychology, York University, ON, Canada Received September 05, 2013; accepted for publication March 18, 2014 Address for correspondence and reprints: Jennine S. Rawana, PhD,131 Behavioural Sciences Building, York University, 4700 Keele St., Toronto, ON, Canada, M3J 1P3, Phone: 416 736 2100 Ext. 20771. E-mail: rawana@yorku.ca Published online 5 May 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/aur.1375 © 2014 International Society for Autism Research, Wiley Periodicals, Inc. LITERATURE REVIEW INSAR 507 Autism Research 7: 507–521, 2014