One heavy burden for autistic people to carry is “camouflaging”—the attempt to hide their autism traits to fit in. Adults with autism who camouflage are eight times as likely to harm themselves as those who don’t, Cassidy’s team has found. Although many autistic adults do camouflage, the phenomenon is thought to be particularly common and damaging among women on the spectrum.
The effort involved in camouflaging contributes to anxiety and depression, compounding the risk of suicide. “I struggle to fit in,” says Richard Carmichael, 17, of North Carolina, who was diagnosed with autism five years ago. “I wear neutral-colored clothing; I try to appear normal at all times,” Richard says. Although he no longer feels suicidal, he says, he did for years.
Suicide is notoriously difficult to predict, but clinicians have a window of opportunity. “For each completed suicide, there are 25 attempts,” says Tami D. Benton, the psychiatrist in chief at the Children’s Hospital of Philadelphia. More than half of all people who die by suicide visit a health-care provider within one month of their death.
In light of that fact, the Joint Commission, a nonprofit accreditation board for U.S. hospitals, recommended in 2016 that hospitals screen all clients for suicide risk, regardless of the reason for their visit.
Screening for depression and suicide is particularly challenging in people with autism, says Lisa Horowitz, a staff scientist and clinical psychologist at the U.S. National Institute of Mental Health. “We have every reason to believe that people with autism have higher estimates of suicide risk” than the general population, she says, but “this is a tricky population to understand.”
In 2008, Horowitz led a multisite study to develop the Ask Suicide–Screening Questions tool, which has four questions and takes about 20 seconds to complete. Nurses or doctors refer anyone who answers “yes” to one or more of the questions for further assessment. The tool was designed for typical youth aged 10 to 24, but last year, Lipkin and his colleagues began using it in their outpatient clinics at the Kennedy Krieger Institute in Baltimore.
The team offered the test to 317 autistic people aged 8 and older over two months in 2017. Roughly one in three of these people declined to take the test. Among the remaining participants, however, 13.7 percent screened positive for suicide risk. Autistic adults and parents of children with autism were more likely to decline the screen than were children and teens on the spectrum, the researchers reported at INSAR. The parents who did agree to the screen, however, were more likely to disclose suicidal behaviors than their children were—perhaps in part because children with autism can have trouble expressing themselves.
Another team has used the screen in the pediatric emergency room of Johns Hopkins Hospital in Baltimore. From May 2013 to December 2016, 42 percent of all autistic children admitted to the facility screened positive on the test; of these, 71 percent did not present with suicidal ideation. “We increase our detection of suicidal kids when we screen for it,” says Holly Wilcox, an associate professor of mental health and psychiatry at Johns Hopkins University. “It gives us a window of opportunity to help them if we can link them up with appropriate services. Oftentimes, the suicidal individual will feel relieved that they were asked and they could disclose their thoughts.”