What if the patients we assume are safest from suicide are actually the ones we miss? Today we're talking about suicide risk in autistic youth, why it's higher than many clinicians expect, how distress shows up differently, and what small changes in our assessment process and treatment can make a real difference.

Publication Date: 06/01/2026

Duration: 18 minutes, 29 seconds

Transcript:

MARA GOVERMAN: What if the patients we assume are safest from suicide are actually the ones we miss? Today we're talking about suicide risk in autistic youth, why it's higher than many clinicians expect, how distress shows up differently, and what small changes in our assessment process and treatment can make a real difference.

JOSH FEDER: I'm Dr. Josh Feder, the Editor in Chief of the Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice, Second Edition 2023, and our other book, Prescribing Psychotropics.

MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of the Carlat Psychiatry Reports. Many clinicians today may still assume autism lowers suicide risk. The thinking goes: more supervision, more structure, fewer opportunities for harm.

JOSH FEDER: But when we look at the data and our clinical experience, a different pattern emerges. Nearly one in four autistic youth report suicidal thoughts (O’Halloran L et al, ClinPsychol Rev 2022;93:102144), more than double the rate in the general population(SAMHSA 2023; www.tinyurl.com/2693jm5j), and they're about five times as likely to attempt suicide (Chen MH et al, J Clin Psychiatry 2017;78(9):e1174–e1179). Yet the warning signs are easy to miss. Much of our suicide assessment training comes from neurotypical populations, so we tend to listen for verbal expressions of hopelessness. We look for social withdrawal or explicit statements of intent to harm oneself, and autistic patients don't always present that way.

MARA GOVERMAN: Autistic youth often experience distress differently. Emotional pain may show up through changes in actions or routines rather than through words.

JOSH FEDER: Many struggle to identify or describe internal emotional states. They may not say they feel depressed even when their functioning is declining.

MARA GOVERMAN: Clinicians may notice increased shutdowns, irritability, rigidity, or loss of interest in routines or special interests.

JOSH FEDER: Another factor is perseverative thinking. That's thinking about things over and over again. Thoughts repeat and become difficult to disengage from, and when suicidal ideation enters that loop, it can persist longer and is hard to interrupt. It's very challenging.

MARA GOVERMAN: Traditional cognitive strategies don't always interrupt that patter neither.

JOSH FEDER: Mara and I have been working with this population for decades, and we've had a number of people who we worry about. And that persistent suicidality is so thorny. It's like any other persistent thinking and the ideas that come with it, like, "I have to die because there's no other choice. There are no other options." It reminds me of the work I did in the past with Edwin Shneidman. He was a suicidologist at UCLA when I was a resident in the Navy. We'd go up once a year and bring our cases of suicide to him to think through them together, all of us resident trainees. He had a three-part way of understanding and addressing suicidality, and when I've talked to suicidologists like Cynthia Pfeffer and others in more recent years, they've endorsed it. Shneidman's model was to look at the three Ps: pain—

MARA GOVERMAN: Uh-huh.

JOSH FEDER: Right, press, and perturbation. Pain meaning how much pain you're in. The press meaning how necessary do you feel it is to act on that right now. And perturbation means, like, how many different choices do you have right now? If you could relieve someone's immediate pain, that would be really helpful. If you could reduce the need to act on that pain right now, that would be helpful. And then finally, if you could give them choices other than death by suicide, well, that would be helpful. So one of the classic examples that Shneidman gave was a person who got a B-minus on an exam in college, and that seemed so painful, and the only answer to that pain was to kill themselves. He would do anything to try to help the person in the moment, just being very proactive and trying to reduce the pain. But you ask the person, "Do you need to do that right now, or do we have some time to try to figure this out?" And finally, and especially with autistic kids, maybe there are other things that you could be doing. Maybe there are other things you like to do or have thought about doing and options in your life.

MARA GOVERMAN: In dysregulated autistic youth, reframing is a very challenging skill set because of their rigidity in thinking. The all-or-none and black-and-white thinking makes it very hard to make those transitions. Clinicians might require adding additional support and scaffolding to model alternative choices because these are people who just might not be in a place to be able to do that on their own.

JOSH FEDER: That's a really good point. When we think about executive function with people on the spectrum, you think about all the different steps, right? Just recognizing there's a problem, and then having some sort of plan to solve that problem, and then figuring out what the steps are, and then executing those steps, and then adapting as you go because nothing ever unfolds the way you expected. So, to your point, there are all those different places where anybody, especially autistic people, can get stuck (CookML et al, Autism 2024;28(9):2311–2321). So they might know the steps, but they don't execute them, or they execute the steps, but when it doesn't happen exactly as they expected, they get stuck. And so, really walking through that with people is important. But in addition to this, autistic youth experience our usual psychiatric problems: depression, anxiety, trauma, social stress, and those are things we need to be thinking about as well.

MARA GOVERMAN: But autism changes how these pressures accumulate.

JOSH FEDER: Yeah, and social rejection, bullying, chronic misunderstanding—those can create ongoing stress rather than isolated events.

MARA GOVERMAN: And masking plays a role too. Many autistic youth spend time and energy trying to appear socially typical. That effort can lead to exhaustion and discouragement.

JOSH FEDER: And like I said earlier, executive functioning challenges also matter. So, transitions, uncertainty, or unsolved problems can feel overwhelming and permanent.

MARA GOVERMAN: Some youth respond with catastrophic thinking, seeing few alternatives when stress arises.

JOSH FEDER: Families and clinicians sometimes assume protective factors exist automatically.

MARA GOVERMAN: High parental supervision may reduce access to lethal means, but it doesn't eliminate suicidal thinking and developing self-care strategies to handle discomfort, disappointment, and dysregulation.

JOSH FEDER: Yeah, and a kid who really has it on their mind to hurt themselves—

MARA GOVERMAN: Mm-hmm...

JOSH FEDER: Could get away from you in a parking lot and run into traffic or do these kinds of things. So, you may be supervising them on the one hand. On the other hand, lethal means are everywhere. And concrete thinking—

MARA GOVERMAN: Mm-hmm.

JOSH FEDER: Doesn't prevent someone from having despair. It may actually make people have more despair because they can't think in an abstract problem-solving way. And that limited independence doesn't remove emotional suffering either.

MARA GOVERMAN: Mm-hmm.

JOSH FEDER: So these things that we think about as protective aren't necessarily solving the problem of suicidality.

MARA GOVERMAN: And as providers, it's helpful to remember that assumptions about protection can delay screening and make us uncomfortable bringing up these topics.

JOSH FEDER: In terms of whether families, teachers, or other people are going to refer for an assessment, when a kid is creating behavioral disturbance, we'll often see kids who people are wondering are safe to be in school, but what we don't necessarily see is when kids are quietly suffering. Maybe they're depressed, suicidal, and not as adept at expressing themselves; they're not referred. And you're right, the assumption is, "Oh, they're in a contained class; they're okay. They're in a safe place." Well, maybe not. And it's a really big challenge that no suicide screening tool is going to work perfectly for all autistic youth. We can't depend on a single questionnaire to catch every case, even with typical kids, but still, routine screening is important. We need to adjust how we ask the questions to match each patient's communication and processing style.

MARA GOVERMAN: So, using concrete language, avoiding metaphors, certainly helps to connect with autistic youth. Define abstract emotional terms. Talk to them as people rather than as patients, rather than just assuming that there's a shared meaning and a comfortableness, as well as trying to invite other people to ask those difficult questions.

JOSH FEDER: So instead of asking, "Do you feel hopeless?" you might ask, "Do you feel like things will never get better?" I tend to avoid question forms because they can put people under pressure. I might say something like, "Seems like you're feeling things are never going to get better," and then I invite them to correct me or not.

MARA GOVERMAN: That's one of the federisims. Questions are hard; statements are easier. We also want to offer structured responses like yes or no, scales, or choices to invite our youth to make comments, expand, and listen to what they're saying.

JOSH FEDER: Another pro tip here is to allow people longer time to respond. Because the silence might reflect just that they're processing the question—

MARA GOVERMAN: Mm-hmm...

JOSH FEDER: Rather than avoiding answering you or something like that.

MARA GOVERMAN: Mm-hmm.

JOSH FEDER: Don't assume they're avoiding the answer. Give them time. You might need

to repeat it. I tend to give people 10 seconds. I count in my head, "One-one thousand, two-one thousand," before I try again.

MARA GOVERMAN: And gathering collateral information from caregivers, teachers, or therapists.

JOSH FEDER: One clinical challenge involves self-injurious behavior.

MARA GOVERMAN: Behaviors like head banging or skin picking may serve sensory regulation, emotional release, or communication rather than suicidal intent.

JOSH FEDER: So assessment has to focus on function.

MARA GOVERMAN: So we need to ask what triggers the behavior, what happens afterward, and also, has the pattern changed?

JOSH FEDER: Behaviors have meaning, and we want to try to figure out what that meaning is, not just make an assumption about it. And so, while we ask what triggers the behavior and what happens afterward, and whether there is a changing pattern, what we're really thinking about is what are the underlying kinds of circumstances that may be driving this. If you've got somebody who has a sensory difficulty and they're prone to dysregulation when they're exposed to heat, right, they're in a hot classroom or something like that, we have to understand that. So I think this really speaks to looking at all the different pieces of that person's individual profile, their sensory and motor function, how they communicate, and using that as part of your understanding of why they may be experiencing what they're experiencing and going in the direction that they're going in terms of feeling distressed and suicidal.

MARA GOVERMAN: Autistic youth might not announce suicidality directly. In fact, they might go very quiet. Instead, clinicians might be urged to observe withdrawal from preferred activities or isolation, increased rigidity or distress during change, reactivity and anxiety, emotional shutdowns or meltdowns, sleep or appetite disruptions, and declining self-care.

JOSH FEDER: These shifts signal distress even when suicidal thoughts are something that the person is not talking about. When we think about intervention for suicidal ideation, we think about having a structure to it and that it's really embedded in building and supporting the relationships around the person, and safety planning is going to work best when we individualize it to the person and keep it very concrete.

MARA GOVERMAN: So visual plans, not just auditory conversations, really help. Written steps and predictable routines often help more than abstract coping lists.

JOSH FEDER: And address the sensory environment, including noise, lighting, transitions, and expectations.

MARA GOVERMAN: Involve and educate families early. Many parents welcome clear guidance on monitoring and communication.

JOSH FEDER: Environmental stressors deserve attention: bullying, isolation, academic mismatch, and unmet support needs. Another Feder pro tip is that nothing ever happens the way we expect. We live in a world where things aren't going to unfold the way we expect, and for autistic patients, sometimes they're more sensitized to that. But as we become more aware that there is a lot of variation and things never happen really the way we expect exactly, well, then you can step back sometimes and think about what you want to do about it, rather than being stuck in the moment of, "Oh, it didn't happen the way I expected."

MARA GOVERMAN: Hospitalization sometimes becomes necessary, but inpatient environments can overwhelm and frighten autistic youth.

JOSH FEDER: Yeah, you've got to advocate for consistency when people are inpatient, like staff continuity, visual schedules, and communication supports.

MARA GOVERMAN: And we have to prepare teams for sensory sensitivities and motor planning differences.

JOSH FEDER: Most inpatient units just aren't very well prepared for autistic people, and we spend a lot of our time consulting to them. Medication can support emotional regulation when symptoms persist, but we're very careful about that.

MARA GOVERMAN: And it's been our experience that many autistic youth respond to lower doses and show sensitivity to side effects.

JOSH FEDER: For depression, SSRIs such as fluoxetine often serve as starting options with gradual titration.

MARA GOVERMAN: For impulsivity or ADHD symptoms, stimulants may improve regulation and reduce emotional volatility.

JOSH FEDER: When rigidity or agitation remains severe, we consider agents like guanfacine before going to antipsychotics.

MARA GOVERMAN: Use antipsychotics cautiously and monitor metabolic and neurologic effects closely.

JOSH FEDER: Long-term suicide prevention in this population focuses less on crisis management and more on connection.

MARA GOVERMAN: Special interests provide identity, mastery, and social entry points.

JOSH FEDER: Communication supports like speech therapy and AAC devices can expand emotional expression.

MARA GOVERMAN: Schools play a major role through social supports, mentoring, and addressing bullying directly.

JOSH FEDER: Protective relationships with understanding adults consistently lower risk.

MARA GOVERMAN: Autistic youth face elevated suicide risk, and warning signs often differ from traditional expectations.

JOSH FEDER: Screen routinely, adapt communication style, and look beyond verbal expression.

MARA GOVERMAN: Support regulation through structure, relationships, and thoughtful medication usage.

JOSH FEDER: Recognition begins prevention, and small adjustments in clinical approach can change outcomes. So, screen every autistic person for suicidality.

MARA GOVERMAN: Today's podcast is inspired by Doctor of Nursing Practice Jessica Giddens' article in our January/February/March 2026 newsletter. We'll link it in the show's notes. And if you found this episode valuable, which we sure hope you did, please share it with others who need to hear this message.

JOSH FEDER: Everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry.

MARA GOVERMAN: And the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding, which helps us bring you unbiased information that you can trust.

JOSH FEDER: Thanks to all of you for tuning in. Until next time, take care. And remember, when you look for good things, more good can happen.