Process must be customized to meet the needs of individuals who have trouble naming and sharing emotions.

Recently, emergency departments nationwide have seen a drastic upswing in young autistic people presenting with suicidal thoughts and behaviors.

In response, Vanderbilt University Medical Center researchers, writing in Pediatrics, have suggested ways that clinicians and emergency department staff can adapt suicide safety plans to meet their special needs and enhance quality of care.

“Autistic youth experience stressors and emotional reactions in ways that are distinct from their peers,” said Jessica Schwartzman, Ph.D., an assistant professor in the Department of Psychiatry and Behavioral Sciences at Vanderbilt. “Our usual approach to managing suicide risk won’t cut it with this population.”

Managing Risks 

“Among adolescents, suicide is the second leading cause of death in the United States, and autistic youth are seven times as likely to attempt suicide as those who aren’t on the spectrum; the rates are wildly high,” Schwartzman said.

All aspects of suicide occur at higher rates in autistic youth, including ideation and planning. Those who also have another serious condition, such as a cardiac or pulmonological comorbidity, experience even higher risks, she added.

In 2019, the Joint Commission health care accreditation agency called for hospitals, behavioral health, and human services organizations to undertake regular suicide screenings and safety planning to reduce risks. In 2020, it extended the requirement to critical-access hospitals, including rural facilities serving people who live far from emergency care sources. Although not focused on autistic patients, the Joint Commission’s website includes videos showing step-by-step how a psychologist and a patient work together to create a plan that reflects that patient’s interests and social supports. The patient then agrees to keep a reduced-size copy of it in their wallet or purse for easy access if suicidal thoughts should reoccur

Planning for Success

When creating a safety plan, an initial step is to identify triggers that might lead to suicidal thoughts and behaviors – warning signs that indicate a potential crisis. Identifying triggers is a critical first step as this information enables clinicians, youth, and caregivers alike to develop a safety plan.

“Most non-autistic youth can quickly recognize and identify what sets off these processes – things like school stress, family dynamics, a breakup,” she said.

This doesn’t hold true for some with autism spectrum disorder.

“Young people on the spectrum often have a hard time identifying what they are feeling and communicating those feelings to others,” Schwartzman said. “To adapt our practices to their needs, we have to use concrete, targeted questions to help youth identify their triggers. 

Also, young people with autism often experience different triggers.

“Many autistic kids experience sensory overload. A loud environment or an unexpected hug can be overwhelming, which can lead to distress,” Schwartzman said.

Additional suggestions for adapting this first step of safety planning for autistic individuals can be found in the Pediatrics article.

Steps in the Safety Plan

Additional steps involve identifying coping strategies, such as hobbies or favorite TV shows, or  social supports, such as a supportive friend or neighbor, that can be effective distractions from thoughts of self-harm.

The safety plan will also list names of close, trusted contacts in whom the person can confide about their suicidal thoughts, along with professional sources of support. Families of at-risk youth are typically involved in crafting the individualized safety plans and play a critical role in reinforcing the plan and maintaining a safe environment.

“Young people on the spectrum often have a hard time identifying what they are feeling and communicating those feelings to others. To adapt our practices to their needs, we have to use concrete, targeted questions to help youth identify their triggers.”

To guide clinicians in adapting the safety planning process for autistic people, the article specifies “strength-based modifications to safety planning,” which may include visual aids or a mood thermometer to deepen conversations about feelings.

Schwartzman also suggests specific questions to ask, including whether they are being bullied at school or have feelings of loneliness. Vanderbilt researchers have previously reported that autistic children are at higher risk for being overweight and for early puberty, which can compound social distress.

Describing the planning process in families with an autistic child, Schwartzman emphasizes the parents’ role.

“Teens don’t care what a random doctor thinks, but rather what they think and what their parents think,” she said. “Clinicians can leverage this parent-child relationship to collaborate on feasible, realistic ways to keep youth safe as families pursue other long-term supports and services.”

About the Expert

Jessica Schwartzman, Ph.D.

Jessica Schwartzman, Ph.D., is an assistant professor in the Department of Psychiatry and Behavioral Sciences at Vanderbilt University Medical Center and a member of the Vanderbilt Kennedy Center. Her research explores risk and protective factors for depression and suicidal thoughts and behaviors in autistic youth and adults and aims to develop targeted interventions.