Safety Planning for Suicidality in Autism: Obstacles, Potential Solutions, and Future Directions

Suicide is the second leading cause of death among US adolescents; data from the Youth Behavior Risk Survey indicates nearly 19% of youth reported seriously considering suicide, and 9% reported a suicide attempt within the past year.¹ To date, suicide research in adolescents has largely been focused on neurotypical youth. Autistic youth experience elevated risk for suicidal thoughts and behaviors,^2–4 with a recent cohort study finding autistic individuals were three times more likely to attempt and die by suicide.⁵ Screening for suicide is a critical first step in identifying youth at risk who may require immediate intervention,⁶ and screening has been successfully implemented across levels of pediatric care that often serve autistic youth. However, efforts to prevent suicide after risk has been identified are not well understood in the context of autism. Although advances in brief interventions to reduce acute suicide risk in neurotypical adolescents who are identified through screening efforts are encouraging, the extent to which these tools are effective in autistic youth remains under-researched, with no evidence-informed guidelines for providers and caregivers. Thus, there is a critical need for research and clinical training in this area.

Safety planning is an evidence-based intervention designed to help people stay safe during periods of acute suicide risk.^7–9 This intervention is efficacious in reducing suicidal ideation and attempts and enhancing treatment engagement in neurotypical adults and adolescents.¹⁰ Safety planning is distinct from a safety and no-suicide contract (ie, patient contracts with provider by agreeing to not engage in self-harm) because it emphasizes developing a concrete plan (including behavioral coping strategies, social supports, professional supports, and methods to create a safe environment) to use during periods of elevated risk. This intervention is well-suited to many health care settings because it can be delivered by a broad range of health care professionals within a single session.

To our knowledge, the safety planning intervention for suicide has not been empirically tested in autistic youth. Only one study has examined clinicians’ knowledge of and confidence in safety planning with autistic youth in predominantly outpatient settings.¹¹ Only 39% of clinicians (74% of whom had master’s degrees in fields such as social work and counseling) knew of safety planning, and only 21% had used it with autistic youth.¹¹ Complicating matters, there are no studies testing the efficacy of the original safety planning intervention with autistic youth, models for provider and caregiver training, nor have there been tests of evidence-informed adaptations to meet the unique interpersonal, cognitive, affective, and behavioral needs of this population. Therefore, it is unclear whether safety planning in its current form addresses the needs of autistic youth. Emerging intervention research demonstrates that autism adaptations to evidence-based interventions (eg, cognitive-behavioral therapy) outperform standard approaches,¹² which suggests that autism-adapted approaches to safety planning may enhance efficacy. Additionally, the noted heterogeneity among autistic individuals further emphasizes the need for individualized safety planning in clinical practice to capitalize on their unique strengths and needs.

To enhance safety planning for autistic youth, future investigations may focus on: (1) identifying risk and resilience factors for and causal mechanisms of suicidality in autistic youth; (2) establishing intervention efficacy; (3) comparing the efficacy of standard approaches to autism-adapted protocols; (4) implementing interventions with providers across settings; (5) developing training models for caregivers, providers, and self-guided manuals for youth; and (6) longitudinal studies testing the impact of these interventions over time at individual and systems levels. In addition, it will be important for researchers to consider insights gained from other safety-focused interventions for autistic youth (eg, pica and elopement), which focus on behavioral strategies to manage safety. These lines of research may afford insights into which intervention models are most effective for autistic youth with the highest return on investment for families. In particular, we believe that autism-specific safety planning interventions that capitalize on the strengths of the youth and family may be especially promising in reducing suicidality and improving quality of life. Notably, one clinical trial was recently funded by the Patient-Centered Outcomes Research Institute to compare autism-specific safety planning interventions for suicide (principal investigators: Maddox and Jager-Hyman; “A Comparison of Two Brief Suicide Prevention Interventions Tailored for Youth on the Autism Spectrum”), a much needed study to begin to unpack these critical clinical research questions.

Given that high-quality research, including the aforementioned clinical trial, may take years to produce outcomes, and providers and families seek immediate solutions, several strengths-based modifications to safety planning are suggested here for autistic youth, informed by existing mental health interventions and reviewed by several stakeholders in the autism community (eg, autistic self-advocates and parents). (For a list of peer-reviewed articles that were used to support these recommendations, see Supplemental Table 1.) Preliminary recommendations for identifying when autistic youth may be at risk include incorporating a youth’s circumscribed interest in discussions regarding warning signs (eg, identify crisis signs in characters of interest) and pairing verbal discussions with visual aids (eg, mood thermometer). These practices may be enhanced by provider consideration of sensory overload and flooding (eg, extreme distress at loud sounds or crowded places) or social burnout (ie, elevated fatigue after situations with high social demands) that may exacerbate a crisis in autism. Emotion recognition is a common method of detecting crisis in safety planning, yet this may be challenging for autistic youth who may present with alexithymia (ie, substantial difficulties in identifying and describing emotional states) or other difficulties in describing and regulating emotions. To address this, providers may use concrete explanations of physiologic signals or behaviors (eg, tachycardia, diaphoresis, frequent crying, and heaviness in body) that may indicate crisis or use worksheets to identify emotions in lieu of verbal explanations.

When identifying strategies to help mitigate suicide risk, providers may consider using visual aids (eg, checklist and safety plan sheet) and concrete instructions (ie, no metaphors) at all stages of safety planning to facilitate consolidation of information in a meaningful way that appeals to cognitive styles found more commonly in autism. To identify internal coping strategies to use in crisis, providers may consider strategies such as time alone in a quiet, sensory-friendly environment and/or engagement in a circumscribed interest, if safe to do so. To identify socialization strategies for distraction and support, providers and caregivers may consider whether typical social supports (eg, calling a friend) are comforting to autistic youth in crisis (eg, in cases in which phone calls are a source of significant anxiety). Collaboration on this portion of a safety plan may be especially beneficial. If approved by caregivers, engagement with online communities (eg, gaming and social media) may be important social supports because these reduce the burden of in-person social interactions.

An important aspect of safety planning for all youth is to determine professional supports (eg, therapist and psychiatrist) and other resources (eg, 24/7 crisis hotlines) that may be readily, feasibly accessed. To facilitate an autistic youth’s engagement with these resources, role play exercises (eg, how to communicate your crisis to others) with provider and caregiver feedback may be particularly helpful in overcoming the social initiation aspect inherent to seeking help.

Lastly, caregivers play a pivotal role in both the development and implementation of a safety plan. When warning signs are noticed by a caregiver, they have an opportunity to support their child in implementing coping strategies identified during safety planning. Of note, autistic youth may experience difficulty in appreciating their caregiver’s level of concern during a crisis. In such instances, encouraging cognitive and concrete (as opposed to affective) perspective taking may be of benefit. Importantly, caregivers are specifically needed to implement lethal means restriction. Although engaging in certain circumscribed interests (CIs) (eg, movies and history) may be an adaptive coping skill for many autistic youth, it is notable that some CIs (eg, in death, weapons, and horror films) may inadvertently serve to enhance suicidal urges or teach youth about additional methods of self-harm. If this occurs, a caregiver can restrict a youth’s access to these CIs and redirect to a more adaptive CI as a component of a safety planning intervention. Developing a parallel, parent-specific safety plan to support parents own emotion regulation and aide them in supporting their child may also be beneficial.

In summary, there is a dearth of research and clinical guidance on safety planning for suicide risk in autistic youth. To address this, suggestions for future lines of research and clinical adaptations for autistic youth were presented. Rigorous, patient-oriented clinical research is needed to improve our understanding of how to best support autistic youth experiencing suicidal thoughts and/or behaviors.