The effect of dialectical behavior therapy in autism spectrum patients with suicidality and/or self destructive behaviour: a multi-site randomized controlled trial.

The prevalence of ASD is 1%: 170.000 patients the Netherlands (Brugha et al.,
2011). Many patients with ASD are treated in long-term specialized care and
suicidal behavior is an issue that troubles patients, families and specialists
in the field. Suicidality in autism is more common than previously thought.A
meta-analysis with the studies in the review by Segers et al. (2014) found 20.4
% of suicidal ideation and 10.0% suicidal behavior in patients with ASD. At
this moment, there is no documented effective therapy for suicidal behavior in
ASD. Yet, there are promising clinical trials conducted with Dialectical
Behavior therapy (DBT) in the participating institutes. DBT is the most
researched and best empirically validated treatment program for chronically
suicidal patients with borderline personality.
Subjects receiving DBT were half as likely to make a suicide attempt, required
less hospitalization for suicide ideation and had lower medical risk across all
suicide attempts and self-injurious acts combined. Subjects receiving DBT were
less likely to drop out of treatment and had fewer psychiatric hospitalizations
and psychiatric emergency department visits. ASD and BPD have many features in
common: both experience problems in emotion regulation, impulse control and
have deficient social skills. DBT addresses these issues. Especially the strict
and repeated behavioral character of the interventions and the building of
emotion regulation skills will be welcomed by the autistic preference for
predictable instruction and rules of conduct.

1. The first aim is to evaluate the effect of a short term DBT treatment
program (26 weeks) versus treatment as usual, in terms of reduction of suicidal
and/or self-harming behaviour in outpatient with autism, suicidality and
self-destructive behavior
2. Secondly, the effects of DBT treatment are asses on anxiety and social
performance, depression, core symptoms of ASD, quality of life and
cost-effectiveness and cost-utility.

A multicenter single blind randomized clinical trial with two arms and 12-month
follow up.

*Dialectical behaviour therapy* will be compared with *treatment as usual*. In
the DBT condition, patients combines weekly individual cognitive behavioral
psychotherapy sessions given by primary therapist with two times a week skills-
training groups lasting 2.5 hours per session. The control condition is
treatment as usual which consists of, at least, weekly sessions of 30-45
minutes with a psychotherapist or social worker

Measurement moments will be at baseline, at end-of-treatment at 6 months and at
follow-up at 12 months. This will take approximately 7 hours in total. There is
no practice-nor evidence based treatment for treating suicidal behavior in
autism. Based on previous positive clinical experiences, we expect patients to
benefit from the therapy. We expect that DBT would be effective in decreasing
suicidal and self-destructive behavioral and to increase quality of life and
increase social functioning.

Research has shown that the participation of suicidal persons to experimental
studies does not lead to more suïcides or more suicide attempts and exclusion
of suicidal subjects does not lead to less suïcides or suicide attempts in
research trials. The questions to the own suicidality of subjects from both the
general population and vulnerable and suicidal populations does not lead to
increase in suicidality. A small group of participants find the questions to
unpleasant confrontational and suicidality (light) but this concerns short-term
effects and participation is nevertheless, typically seen as valuable (Huisman
en Kerkhof 2017). Dialectical Behaviour therapy (DBT) is the most researched
and best empirically validated treatment program for chronically suicidal
patients with borderline personality. Prior use of Dialectic Behaviour therapy
(DBT) have caused little or no damage. Damage can occur in emotional stress ,
similar to regular cognitive -behavioral treatment. Generally, the group is
rigid in behavior and habit and we see no additional risks with standard
treatment DBT. Therefore, we estimate the risk of injury as small. We do not
expect any aversive events and these are not documented