Suicide Risk and Intellectual or Developmental Disability
- Please note that diagnostic categories described herein are translated directly from the research articles, whereby we are conscious that some typologies may have changed from the date of the research publications, and according to different jurisdictions.
There are a number of specific populations that have been considered with respect to suicide risk. One of the less understood and considered populations relate to those with intellectual and developmental disability. The following is a brief summary of (the limited) findings in research over the past ten years approximately.
Foetal Alcohol Spectrum Disorder
Prenatal exposure to alcohol, can cause neurological damage to the developing foetus, resulting in cognitive impairment and physiological abnormalities (Wozniak, Riley & Charnes, 2019). The condition is known as Foetal Alcohol Spectrum Disorder (FASD) and as the name suggests, the person’s level of disability can lay on a spectrum from significant functional impairment through to more mild presentations, which can complicate diagnosis. Given the symptoms lay on a spectrum, understanding suicidality is often in the context of identifying known risk factors for suicide, such as impulsivity, impaired judgement and emotional regulation difficulties (Huggins et al., 2008). What is less well recognised are the opportunities for intervention, particularly in the context of suicidal behaviours.
Cassidy and associates (2014) investigated the association between Asperger’s syndrome and suicidality. They found that people diagnosed with Asperger’s syndrome were nine times more likely to die by suicide than the general population, and these rates were even higher if they also had symptoms of depression and ‘autistic traits’ (Cassidy et al., 2014). This is a rather alarming finding and while they conceded that more research was needed, they related that cognitive inflexibility, difficulties socially and family history of suicidality and aggression may play roles in these rates.
Autism Spectrum Disorder
Consistent with Asperger’s Syndrome, research has demonstrated that people diagnosed with Autism Spectrum Disorder can experience higher rates of suicidal ideation and planning, however, research by Kirby and colleagues (2019) evidenced that death by suicide was at the same rate as the general population. Exceptions to this were that females were three times more likely to die by suicide than the general population. This research highlighted the high prevalence rates of comorbid psychological conditions, such as depression and anxiety. The rates of comorbidities for people with Autism appear to confound the causal mechanisms underpinning suicide, whereby further research is needed.
In summarising Merrick and colleagues (2006) research on this topic—an analysis of research undertaken across UK and the USA regarding suicide risk in intellectual disability —a number of key issues were reported.
They found that the risk factors for suicide in people with intellectual disability were consistent with those of the general population, including;
- Sexual and physical abuse
- Family and social support
- Mental health problems
- Experiencing significant stress
However, people with intellectual disabilities are noted to have a greater potential for exposure than then general population (Wark et al., 2018). In Australia, almost 32% of individuals with intellectual disability also have a mental illness (Morgan et al., 2008). Given these correlates, the question is relevant—are people with intellectual disability at greater risk for suicide than the general population?
Merrick and colleagues (2006) noted that the severity of intellectual disability played a role in the person’s capacity to comprehend death and their capacity to plan and enact suicide. As such, they noted that those individuals with mild to moderate intellectual disability were at greater risk than moderate, severe or profound intellectual disability due to their capacity to conceptualise their circumstance. Of interest, one study reviewed by Merrick and associates (2006) highlighted the role of anxiety and stress as being relevant in the onset and maintenance of suicidal ideation. As such, the data that reports that people with intellectual disability die by suicide at the same rates as the general population, doesn’t represent the more vulnerable sub-group, namely those with mild to moderate intellectual disability.
Given the risks for suicide are consistent between general population and those with intellectual and developmental disability, it is evident that as practitioners, there are several factors to be aware of, including;
- How to identify and understand the person’s perception of risk, with respect to the nature and severity of death or suicidal ideation
- How their impairment may affect their use of language and communication
- The capacity to which a person is able to comprehend not only questions but potential interventions or supports.
- The extent to which their behaviour, mood and presentation has changed from their usual state.
It could be argued that one of the most critical factors here is the ability to listen and take time to understand the individual, rather than any formal screening process or assessment.
An interesting concern with respect to working with people who have an intellectual or developmental disability, is the workers’ willingness to talk with a person about their distress and specifically, suicidality. This has been a considerable limitation and concern in responding to people with intellectual and developmental disability, where failure to identify risk was due to workers perceptions that they ‘can’t’ ask a person with cognitive difficulties to talk about suicidality, as it made them feel uncomfortable (Ludi et al., 2012; Wark et al., 2018).
Interventions and safety planning were also reported to be consistently effective with individuals with intellectual disability, with the proviso that it is matched to the person’s capacity. Cognitive Behavioural Therapy and behavioural interventions are highly recommended, where a person has the capacity to practice and adapt their behaviours. In safety planning, collaborating with the client, engaging caregivers and services in the safety plan and maintaining consistency were also highlighted as important factors.
When personality factors are also influencing suicidal behaviours, we can’t forget the importance of rewarding desirable behaviour and acknowledging positive coping strategies.
Cassidy, S., Bradley, P., Robinson, J., Allison, C., CmHugh, M. & Baron-Cohen, S. (2014). Suicidal ideation and suicide plans or attempts in adults with Asperger’s syndrome attending a specialist diagnostic clinic: A clinical cohort study, Lancet Psychiatry, 1, 142-147, http://dx.doi.org/10.1016/ S2215-0366(14)70248-2
Huggins, J., Grant, T., O’Malley K. & Streissguth, A. (2008). Suicide attempts among adults with fetal alcohol spectrum disorders: Clinical considerations, Mental Health Aspects of Developmental Disabilities, 11(2), 33-41
Kirby, A., Bakian, A., Zhang, Y., Bilder, D., Keeshin, B. & Coon, H. (2019). A 20-Year study of suicide death in a statewide autism population. Autism Research, 12, 658-666. DOI: 10.1002/aur.2076
Ludi, E., Ballard, E., Greenbaum, R., Pao, M., Bridge, J., Reynolds, W. & Horowitz, L. (2012). Suicide risk in youth with intellectual disabilities: The challenges of screening. Journal of Developmental and Behavioural Paediatrics, 33(5), 431-440
Merrick, J., Merrick, E., Lunsky, Y. & Kandel, I. (2000). A review of suicidality in persons with intellectual disability. The Israel Journal of Psychiatry and Related Sciences, 43(4), 258-264
Morgan, V., Leonard, H., Bourke, J. & Jablensky, A. (2008). Intellectual disability co-occurring with schizophrenia and other psychiatric illness: Population based study. British Journal of Psychiatry, 193(5), http://www.idrs.org.au/s32/_guide/p040_4_2_IDandMI.php#.VvZwHP9pBMs
Wark, S., McKay, K., Ryan., P. & Muller, A. (2018). Suicide amongst people with intellectual disability: An Australian online study of disability support staff experiences and perceptions. Journal of Intellectual Disability Research, 62(1), 1-9. DOI:10.1111/jir.12422
Wozniak, J., Riley, E. & Charness, M. (2019). Clinical presentation, diagnosis and management of fetal alcohol spectrum disorder. Lancet Neural, 18, 760-770, http://dx.doi.org/10.1016/ S1474-4422(19)30150-4