A Systematic Review of the Risk and Protective Factors for Suicide in Autism Spectrum Disorder
Clinical Snapshot
PICO Framework
| P — Population | Autistic individuals (diagnosed with Autism Spectrum Disorder) across the lifespan, including children, adolescents, and adults |
| I — Intervention | Exposure to identified risk factors (psychiatric comorbidities, bullying, cyberbullying, teacher harassment, cognitive factors, social isolation) or protective factors (social relationships) |
| C — Comparator | Autistic individuals without identified risk/protective factors, or general population comparators where reported in included studies |
| O — Outcomes | Suicide-related behaviours, including suicidal ideation, suicide attempts, and completed suicide; identification of modifiable risk and protective factors |
Bottom Line
This systematic review synthesises evidence on risk and protective factors for suicidal behaviour in autistic individuals, drawing on 19 empirical studies. The key risk factors identified — psychiatric comorbidities, bullying, cyberbullying, teacher harassment, and cognitive difficulties — are clinically recognisable and should prompt heightened vigilance during mental health assessments of autistic patients. Social relationships emerge as the primary protective factor, reinforcing the importance of social connectedness interventions. However, the review's conclusions must be interpreted cautiously. The narrative-only synthesis, absence of pooled effect sizes, unconfirmed risk of bias assessment, and limited evidence base (19 studies) constrain the certainty of findings. No GRADE ratings are provided, and protective factor evidence is explicitly acknowledged as sparse. For Australian clinicians, this review reinforces the need to routinely enquire about suicidality, bullying victimisation, and social isolation in autistic patients across all age groups and settings. It does not, however, provide sufficient evidence to mandate new screening protocols or alter prescribing practice. The findings are best used to inform clinical vigilance and to advocate for autism-specific suicide prevention research and policy development in Australia.
Key Findings
P Value: Not reported at the review level
Effect Size: Not quantified; narrative synthesis only. Risk factors identified include psychiatric comorbidities, bullying, cyberbullying, teacher harassment, and cognitive functions. Social relationships identified as a protective factor.
Primary Outcome: Identification of risk and protective factors for suicide-related behaviours in autistic individuals across 19 included studies
Nnt Or Sensitivity: Not calculable from this review. No NNT, sensitivity, specificity, or hazard ratios reported. Individual study-level statistics not synthesised.
Confidence Interval: Not reported; no meta-analysis conducted
Clinical Application
The identified risk factors (psychiatric comorbidities, bullying, social isolation, cognitive difficulties) are clinically assessable in routine practice. Screening for these factors during mental health assessments of autistic patients is feasible without additional resource burden. However, validated suicide risk screening tools adapted for autistic populations remain limited, and standard tools may not capture the unique phenomenology of suicidality in autism. In Australia, autism affects approximately 1 in 70 people (Australian Bureau of Statistics, 2018 Survey of Disability, Ageing and Carers). The RACGP and the National Disability Insurance Scheme (NDIS) both recognise the elevated mental health burden in autistic Australians. Suicide prevention in autistic individuals is not yet a discrete focus of the National Suicide Prevention Strategy, representing a policy gap. The TGA has not approved autism-specific pharmacological interventions for suicidality; management relies on treating co-occurring conditions (e.g., depression, anxiety) with PBS-listed agents. Clinicians should note that standard suicide risk assessment tools (e.g., Columbia Suicide Severity Rating Scale) have not been validated in autistic Australian populations. The RACGP's 'Red Book' preventive health guidelines do not currently include autism-specific suicide risk screening recommendations, suggesting an area for future guideline development. Autistic children, adolescents, and adults presenting to mental health, paediatric, general practice, or neurodevelopmental services. Particularly relevant for those with co-occurring psychiatric conditions, history of bullying victimisation, or social isolation.
Abstract
The shorter lifespan and increased prevalence of physical and psychiatric comorbidities in autistic people is a challenge for mental health. There is a high risk of suicide-related behaviors in autism, which are related to mental health issues, social isolation, and other factors. Here we aimed to systematically review the evidence on risk and protective factors of suicidal behaviors in autistic people. Electronic datasets (PubMed, Scopus, Web of Science, and PsycInfo) were searched for empirical articles on the risk and protective factors for suicide in autism. The PRISMA guidelines were followed, and a series of inclusion and exclusion criteria were applied to the retrieved data. This review included 19 studies reporting multiple risk factors associated with suicide-related behaviors. Noteworthy contributors among these factors include psychiatric comorbidities, bullying, cyberbullying, teacher harassment, and cognitive functions. The evidence for protective factors is limited; however, social relationships are highlighted. Identifying risk and protective factors is paramount for detecting early warning signs and enabling the prevention and intervention of suicidal behavior. Our review identified key sociodemographic, clinical, and cognitive risk factors to take into account as alarm-signs when identifying suicidal behaviors in autism.
References
- 1.Tubío-Fungueiriño, M., Cruz, S., Conde-Pumpido-Zubizarreta, S., Pozo-Rodríguez, M., Hervás, A., Carracedo, A., & Fernández Prieto, M. (2026). A systematic review of the risk and protective factors for suicide in autism spectrum disorder. The Spanish Journal of Psychology. https://doi.org/10.1017/SJP.2026.10034
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