Daniel is a 13-year-old autistic teen brought in by his parents after saying, “I hate my life” and “I want it over.” His family is stunned—they had assumed his developmental differences protected him from suicide risk.

Many families, and clinicians, believe that traits like concrete thinking or high supervision reduce suicide risk in autism. But autistic youth are at significantly higher risk than their neurotypical peers.

In this update, we walk you through how to recognize suicide risk in autistic youth, adapt screening tools, and intervene using practical, autism-informed strategies.

Autism and suicide risk 
Autistic youth are more likely to think about, attempt, and die by suicide than neurotypical peers:

• Nearly one in four report ­suicidal thoughts (O’Halloran L et al, Clin Psychol Rev 2022;93:102144)—more than double the rate in the general population (SAMHSA 2023; www.tinyurl.com/2693jm5j).
• They are five times as likely to attempt suicide (Chen MH et al, J Clin Psychiatry 2017;78(9):e1174–e1179). 
• Completed suicide is over four times more common in autistic youth ages 10–19 (Kõlves K et al, JAMA Netw Open 2021;4(1):e2033565). 

Fewer than half of clinicians routinely screen autistic youth for suicide risk, and that is especially concerning since signs of suicidality are harder to spot in this population.

Suicide risk presents differently in autism
Autistic youth experience many of the usual risk factors—depression, anxiety, trauma—but these often interact with autism-specific features in clinically important ways:

• Repetitive suicidal thoughts may get stuck due to perseverative thinking. These loops are difficult to interrupt with traditional cognitive strategies.
• Sensory-motor differences shape how the person experiences and interacts with the world, requiring different approaches to challenges like loneliness or bullying. 
• Communication differences make it harder to express distress. Some youth can’t explain how they feel or don’t bring it up until the situation becomes urgent.
• Social stress is common. ­Bullying, rejection, and the mental effort of masking contribute to ­hopelessness (Cancino-Barros I et al, Sci Rep 2025;15:22885; Dell’Osso L et al, Brain Sciences 2025;15(10):1114).
• Executive functioning challenges make it harder to manage transitions and solve problems—both common suicide triggers (Cook ML et al, Autism 2024;28(9):2311–2321).
• Other risk factors include PTSD, gender dysphoria, and family or financial instability (O’Halloran et al, 2022).

Some traits offer limited protection. High parental supervision can reduce access to lethal means, and some youth may lack the motor planning needed to act on suicidal thoughts. But these factors are not protective enough to skip screening. 

Suicide screening in autistic youth
Routine screening, just like you’d do for any other high-risk group, helps you catch concerns before they become crises. No screening tool is validated across the full range of autistic youth. Adapt standard tools like the PHQ-9 or C-SSRS for most patients (Reid M et al, Curr Psychiatry Rep 2024;26(11):563–572). For adults without intellectual disability, consider the Suicidal Behaviors Questionnaire–Autism Spectrum Conditions (SBQ-ASC).

Here are some practical tips when conducting a screening:

• Use simple, concrete language. Explain terms like “hopeless” or “worthless,” and avoid metaphors.
• Offer yes/no questions or multiple-choice answers.
• Allow extra time for responses, especially if the youth uses an Augmented and Alternative Communication (AAC) device or other communication supports.
• Get input from parents, teachers, or therapists. Many autistic youth do not verbalize suicidal thoughts directly.

Distinguishing suicidality from other behaviors
Some behaviors, like head-banging, self-biting, or skin-picking, may look like self-harm but serve a different purpose in autistic youth. Ask yourself:

• Is this about sensory-motor challenges?
• Is it a way to communicate distress?
• Or is it a sign the youth wants to die?

You may not get a clear answer. In those cases, look for changes in frequency, intensity, or context, and rely on ­caregiver insight. 

What to watch for
Autistic youth may not express suicidality in the ways you’re used to. Instead, you might see:

• Loss of interest in a special interest or routine
• Increased emotional outbursts or shutdowns
• Social withdrawal
• Unusually rigid or catastrophic thinking
• Sudden changes in sleep, eating, or hygiene

These shifts may indicate distress, even if the youth denies suicidal thoughts. Ask caregivers and teachers what they’ve noticed. 

Where to start if the risk is present
Start by supporting responsive relationships with parents and others in a context of structure and safety. 

• Create a personalized safety plan. Include strategies to support regulation, connection, and meaningful interaction with parents, peers, and others.
• Reduce sensory-motor distress. Provide calm spaces and predictable routines. Assess signals of distress, and judge whether physical contact or eye contact is helpful or ­distressing. 
• Educate families. Explain that autism does not reduce suicide risk and may even increase it. Offer guidance on monitoring and communication.
• Address environmental problems such as social isolation, bullying, or inadequate academic support.
• The Autism Friendly Hospital Initiative has additional forms and tips for the emergency department and other clinical spaces (www.tinyurl.com/enz4p57t). 

Inpatient care
If hospitalization is needed, look for a psychiatric unit with autism-specific supports. If that’s not available:

• Ask for consistent staffing, visual schedules, and communication supports.
• Alert the team to sensory and motor planning challenges and possible distress triggers.
• Avoid restraint or seclusion unless absolutely necessary. 

Medications: Go low and slow
Autistic youth often respond to lower doses and are more sensitive to side effects.

• Depression: Fluoxetine is a reasonable starting point. Begin at 5–10 mg daily and titrate slowly. Watch for activation (Siegel M and Beaulieu AA, J Autism Dev Disord 2012;42(8):1592–1605).
• ADHD/impulsivity: Methylphenidate (5 mg BID) can help with emotional regulation and reduce suicide risk. Monitor for appetite, sleep, anxiety, and irritability.
• Severe rigidity or agitation: After nonpharmacologic efforts, consider milder medications such as guanfacine or fluoxetine. Use antipsychotics only when other approaches have failed and only in low doses (risperidone 0.25–0.5 mg or aripiprazole 2–5 mg). Monitor closely for metabolic and neurologic effects. See our Child Medication Fact Book for Psychiatric Practice, Second Edition (2023) for an algorithm to guide your thinking. 

Long-term supports that lower risk

• Leverage special interests. They offer structure, identity, and social ­connection.
• Use AAC or speech therapy to build communication around emotion and distress.
• Involve schools. Advocate for autism-informed mental health supports, social skills groups, and mentor programs.
• Address bullying directly. Ask about peer conflict and use validated screening tools like the CABS or My Life in School Checklist (Graves KA et al, Int J Environ Res Public Health 2024;22(1):29).

Strengthening relationships, especially with adults who understand autism, is key to suicide prevention. 

Daniel now works with an autism-informed therapist who uses visuals to explore emotions. He starts fluoxetine at 5 mg, and you work with his parents to create a structured safety plan. A teacher helps him launch an orchestra club built around his special interest. Three months later, Daniel is engaged, connected, and no longer expressing suicidal thoughts.

Carlat Verdict: Autistic youth are at elevated risk for suicide, and the signs are easy to miss. Screen routinely, adapt your tools, and don’t rely on verbal expression alone. Support emotional regulation with structure, communication aids, and careful medication use. Prevention starts with recognition, and a few small adaptations can go a long way.