Type, content, and triggers for self-injurious thoughts and behaviors in autistic youth and their disclosure to caregivers
Authors: Schwartzman Jessica M , Rubin Alex , Fox Kathryn R. , Hedley Darren , Bettis Alexandra H 
Published: December 2024

Rates of self-injurious thoughts and behaviors are elevated among autistic youth, yet research is limited to caregiver report or single-item questionnaires. Investigation of specific suicidal thoughts, triggers, and disclosure is needed to improve risk assessment and interventions. The current study characterized self-injurious thoughts and behaviors in a sample of autistic youth without intellectual disability presenting for outpatient psychological services. The Columbia-Suicide Severity Rating Scale and qualitative follow-up questions were administered to 103 autistic youth (10–17 years of age). Most autistic youth ( n = 86; 83.5%) reported lifetime suicidal thoughts. Suicide thought content most commonly included abstract thoughts of dying/suicide ( n = 20; 23.3%) and death by cutting ( n = 13; 15.1%). Half of youth experiencing suicidal thoughts ( n = 43; 50.0%) denied disclosure to their caregiver. Nearly one in four youth attempted suicide ( n = 25; 24.3%), and some youth ( n = 16; 15.5%) sought help from caregivers to prevent an attempt. Sadness/depression and bullying/teasing were the most commonly reported triggers of suicidal behaviors. Among autistic youth with lifetime nonsuicidal self-injury ( n = 52; 50.5%), head hitting ( n = 28; 45.2%) and cutting ( n = 20; 32.3%) were the most reported types. Findings underscore the importance of targeted prevention and intervention to address self-injurious thoughts and behaviors in autistic youth and continued research to understand barriers and modifiable factors to facilitate self-injurious thoughts and behaviors disclosure. Lay abstract Self-injurious thoughts and behaviors are high among autistic youth, yet research most often relies on caregiver reports and does not include youth perspectives. Relatedly, specific characteristics of self-injurious thoughts and behaviors (e.g. type of behavior, thought content, triggers), and choices to share these thoughts and behaviors with caregivers/parents (or not), have not been studied in autistic youth. With limited information on self-injurious thoughts and behaviors in autistic youth, clinicians and families supporting autistic youth in crisis continue to experience major challenges to best assess and support youth. Therefore, to begin to understand youth perspectives of self-injurious thoughts and behaviors, we administered a self-injurious thoughts and behaviors clinical interview (Columbia-Suicide Severity Rating Scale; C-SSRS) to 103 autistic youth without intellectual disability (10–17 years of age) at a clinic for outpatient mental health services. We added follow-up questions to the interview about suicide to better understand what youth think about when it comes to suicide, what triggers them to feel suicidal, and whether they let their caregiver know about what they are thinking and feeling. Results show that most autistic youth reported suicidal thoughts at some point in their life ( n = 86; 83.5%), with thoughts of dying/suicide ( n = 20; 23.3%) and death by cutting ( n = 13; 15.1%) as common thought content. Half of youth experiencing suicidal thoughts ( n = 43; 50.0%) did not share this with their caregiver. Nearly one in four youth had attempted suicide at some point in their life ( n = 25; 24.3%), while some youth ( n = 16; 15.5%) sought help from caregivers to prevent an attempt. Sadness/depression and bullying/teasing were the most common triggers of suicidal behaviors, while anger/frustration was the leading trigger for nonsuicidal self-injury. Findings can be used to improve current assessment tools and prevention approaches for autistic youth to create better support for autistic youth in crisis.