If I came up to you and told you in a very matter of fact tone that my arm hurt so much I thought it might be broken but I wasn’t crying or appearing distressed, would you believe me? Would my lack of visible emotion make you doubt my pain? What if it were something harder to objectively measure, like a migraine. And it’s lights or fragrance that is causing my migraine due to my sensory sensitivities, but you don’t perceive them as bothersome. Would you believe me? Now imagine that instead of physical pain we are talking about emotional pain or abuse.

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People often ask what is the point of an autism diagnosis. I cannot answer this for you, but I can tell you how understanding my brain has helped me and how it has helped others I know with similar wiring. For most of my life I was pathologized. I was told that something was wrong with me and that if I did some kind of therapy or took some kind of medication I could fix the thing. I was wrongly labeled, wrongly medicated and traumatized by the professionals I went to for help. Had I been taught earlier about how my brain worked, my life would have been profoundly different. The result could have been a more protective, less traumatizing path. This is true for many autistic people.

I want to speak specifically about why autism can be important to understand in the context of abusive relationship dynamics. Almost 90% of autistic women have reported experiencing sexual violence. NINETY PERCENT. This statistic should give every parent, every teacher, every professional bound by mandatory reporting laws, and every human who cares pause. There are many factors that I believe contribute to this. Below I want to name a few significant ones and explain how understanding autism at a systemic level can be protective, or even lifesaving.

Communication Barriers and Masking

Autism is a developmental disability. Many of us who are female presenting with high IQ are not identified as autistic until much later in life (if at all). This means that we go through much of our life using our intelligence to compensate, to mask or camouflage. This takes an enormous amount of energy and comes at a great cost. It is almost impossible for me to articulate what this feels like from the inside. You don’t see “developmental disability” on the outside, you may see “quirky” or “slow” or someone who looks tired. However, this is not what we are experiencing on the inside. We may experience great distress. We may be many years behind our peers as far as understanding subtle social cues or nuance. We may not be able to name or regulate emotions well. But we aren’t identified or supported properly because we get straight As. Instead we are shamed and told to try harder. Over time, we internalize the belief that something is fundamentally wrong with us.

Bullying and Social Isolation

We may become isolated from our peers and picked on because we feel different. Still, we keep trying to figure it out. We want so desperately to belong. This can make us particularly vulnerable to abuse. We are often so misunderstood, but we spend a lot of our time trying so hard to understand everyone around us. Many of us are hyper empathetic. We are not only overly sensitive to lights, smells, and sounds, we are also overly sensitive to emotions. Not just ours. Yours too.

For some of us, that desire to belong can become a very intense attachment around one person that feels intense, consuming, and hard to regulate. When you consider all of these factors together, it is not difficult to understand how autistic people can end up in abusive relationship dynamics. We see a wounded person, animal, a noble cause, and we want to help. Often at our own expense. We typically aren’t taught proper boundaries or how to prioritize our own needs and safety. Without that education, our empathy can become a liability rather than a strength. It can be exploited.

Better Professional Training and Earlier Identification

Autistic people need to understand how our brain works, and we need others to understand it too. Professionals, especially, must learn how to support us properly so we stop being mislabeled, misidentified, misunderstood, and retraumatized.

Professionals need better training on how to identify and support autism even in the absence of a formal diagnosis. Professionals need to understand that not everyone can identify feelings, rate pain on a scale of 1-10, and that flat affect does not mean lack of distress. Professionals need to learn how to honor and accommodate sensory needs (not minimize or dismiss them) and not automatically pathologize someone who experiences the world differently. Teach professionals about delayed processing. Normalize that we need time to understand things. Circling back to add information or ask clarifying questions isn’t a defect, it’s just how our brain works.

Sex Education for the Autistic Brain

We need sex education specific for the autistic brain. We are literal thinkers, we are generally honest and we expect others to be honest too. When that assumption is violated, the consequences can be devastating, especially in sexual contexts.

Neurotypical sexual education is vague. Autistic people don’t do well with vagueness or metaphors. We need clarity and detail. What is consent? What is coercion? When can I say no? What if I change my mind? How do I get out of a situation? We need concrete and specific examples. Give us scripts to use. Teach us about subtle manipulation tactics (love bombing, blame shifting, gaslighting, silent treatment) so we can recognize abuse when it is happening and not after the fact, often decades later.

Real Inclusion and Acceptance

Real inclusion is not kindness weeks or token gestures. It is year-round understanding that reduces isolation and vulnerability. When autistic people are genuinely included and respected for who we are, we are less likely to become targets in the first place.

Actual Accountability for Abusers

Finally, Believe Autistic Survivors. When we are believed, abusers can be held accountable. Include our lived experiences in research. Let us help guide policy and best practices. This is the most basic step, and it is often the most violated. Listen to us. Believe us. Stop gaslighting and dismissing us. We are here. Our stories and our lives matter.

Parents who have lost children is a club that I wish had no members. I saw a post from a fellow child-loss Dad, who had been given a very cherished gift from his son. A simple but sweet coffee mug. Unfortunately, that cup tumbled from his grasp and shattered. With it the fragile veneer of OKness broke too. We pretend till we can’t, we erupt and quake until we don’t.

Every token gift, every art piece, photograph, and place you have gone with your child becomes sacred. But even sacred things and places follow the law. Laws of physics, gravity, and even entropy. The mug is a thing. And if it slips from your hands it accelerates toward earth following the laws. Things aren’t important, people are. But both can be broken, and even with the most meticulous level of kintsugi1, not all broken things are able to be made the same again. The thing becomes enmeshed with our memories, our feelings, and our hearts, but the physical state change permanently alters.

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Feelings are for Feeling

It is truly difficult to feel it all, or even a little bit of it some days. I appreciate everyone bringing Drew Petersen to Boise for his “Feel it all” screening. His calling, his raw and honest discussion on life, mental health challenges, hope, love, and the need for vulnerability is a state change that is so desperately needed. Clearly his story is evidence that we often climb the hardest mountains not because it’s fun, not because it feels good, and definitely not because you’re aiming to be liked, but because it needs to be climbed. Our soul needs to climb it. But also, that climbing the hill might not be enough. It might be a distraction from the change that is needed. The climb might be out of a sense of obligation, or a false sense of duty. We keep climbing because we are told that it is the path that society will reward you for climbing. Maybe it isn’t even the mountain we are meant to climb, maybe it is a path to a sense of achievement that we seek from others, and not one of fulfillment. It is very difficult in life to know when it is best to turn around from the hill we are climbing, and climb one more befitting of our own true selves.

The illuminated path of fulfillment is blocked by layered boulders of socially constructed “niceness.” Protected by institutional habits that defend the status quo, preserve funding streams, pathologize truth tellers, and silence the vulnerable. If you learned anything from Maisa, it’s that kindness doesn’t always come wrapped in sweet phrases or agreeable smiles. True kindness insists on truth, even when truth is the least agreeable guest at the table. Even with a healthy dose of snark. Kindness is often uncomfortable.

A little while back, I wrote about the lesson Maisa taught me about the difference between being nice and being kind in Follow the Money. “Nice” will keep things comfortable and compliant, but “kind” is willing to disrupt comfort for justice and change. Nice enables abusers and toxic systems. Institutions, especially government and public education, are notorious for wielding “nice” as a shield while simultaneously dodging hard conversations about disability, mental health, and institutional failures or crimes. The reflex seems to be to meet tragic loss with platitudes, memes, or silence. The price for that illusory comfort, too often, is paid in the currency of the suffering children who don’t fit the mold, or can’t keep up despite being told that they won’t be left behind. Worst of all, the price is paid not by those institutions that seek to cover totems of discomfort and failure in sand to avoid changing their default state. Just like the coffee mug must follow the law of physics on its path to the hard floor, I want our schools to follow the law that we have to guide our institutions to protect those that most need protecting. Change isn’t easy.

Using one Broken System to Kintsugi Another

It’s nice to have meetings, assemble committees, and post photos about “celebrating neurodiversity.” But real kindness means confronting the perverse monetary incentives, the budget-driven attendance formulas that push kids beyond their breaking point, and the deep-rooted aversion to identifying disabilities that don’t fit the budget. We have been marginalized, shunned, excluded and ignored. We have sent nice e-mails and letters. We have sent demand letters and requests for dispute resolution. They were all completely ignored.

Maisa’s sign as a Libra fits with her strong innate sense of justice. She often was seeking balance in the scales. I have a somewhat jaundiced eye toward litigation. It is difficult to cipher what can, and what cannot be fixed with litigation in the legal system. Filing a lawsuit isn’t “nice.” Litigation is agonizing. It is excruciatingly expensive, painful and retraumatizing. It means reliving every ignored warning, every unanswered cry for help, every bureaucratic sidestep. And there were a lot of them. Over many years.

A past version of myself, fresh from Twin Falls High School, was pretty decent at climbing hills. I decided to climb the hill all the way to law school at Duke, to keep climbing and climbing, but the bankruptcy lawyer suit never seemed to quite fit. I decided to make a change, and not practice law. I decided to go back to the farm, back to Idaho, to make farm loans. Maisa called me “Farmer Yams.” I surely had moments where I questioned the decision, the loan debt, and whether it was, in hindsight, a poor idea to have gone to law school. But I also knew it was my path, and that path is what led me here. To now. Maybe there were more reasons for me going to law school than I knew at the time. Perhaps it was to get me ready to climb another difficult hill.

If litigation is a hill, it is more like Mount Trashmore than Mount Justice. But sometimes it is the only path to use one broken system to try and reform another. The path toward justice, to change, to truth. That is why we decided, after much deliberation, soul searching, and research to pursue a lawsuit against the Boise School District and Idaho Department of Education. I wish it were different, but it appears that litigation is the only love language they are hearing right now. Our attempts to resolve our issues via other routes were completely ignored. I wish many things were different. I wish I had more help. If you are an attorney willing to help litigate, to advocate for the rights of disabled children, we would love the help. Just call for help right?

That’s why this federal complaint was filed; not as an act of grief or self-serving anger, but as an act of radical kindness and civil action to promote long overdue systemic change. The lawsuit screams in legal jargon, that the status quo is unacceptable. It harmed us, it continues to harm disabled and vulnerable children every moment until we collectively decide to make changes. It will take more than a t-shirt, a pithy sign filled with royalty puns to make this better. It takes all of us. To stop accepting the unacceptable so that we don’t have to bear the unbearable.

Hear thee, Hear thee the complaint alleges, in part

• Systematic and continuing refusal to identify, assess, or support disabled children, in direct violation of federal laws (Section 504, ADA, IDEA).

• Deliberate indifference from the school district and Idaho Department of Education toward students with disabilities and mental health needs, triggered by policies that punish the disabled and reward the compliant.

• Death, trauma, and exclusion are not each finite isolated tragedies, but are predictable outcomes of policies designed to maintain appearances and protect budgets.

• Destruction of records, silencing displays of grief, and retaliatory measures when families refuse to “play nice” and push for change.

It’s tempting to think that waving a protest sign, sending a heartfelt email, or posting a hashtag might break down institutional silos. Unfortunately, institutions have immune systems built to repel discomfort and insulate authority. The fight for kindness sometimes requires the sharp tool of litigation. Maybe we can use one branch of judicial power to force another branch to do what the legislative branch already has told it to do.

And let’s be clear, this isn’t war on teachers, staff, or even most administrators as individuals. They need more support too. The system itself, built around perverse incentives and survival reflexes, is what stands between our kids and the support they deserve. Litigation is the kind thing to do, not because it’s easy, but because it forces accountability, compels introspection, and rips off the bandage of denial. Lady justice is blind, but not powerless, and she stands as the legal right and obligation to seek accommodation for her, and our children’s disabilities. Sometimes the kindest act is to disrupt, to challenge, to speak truth to power, and to refuse to pretend. Sometimes the justice Maisa loved means stepping into the courtroom, not the principal’s office, because only then can institutions be forced to remember the children they left behind.

It’s past time for Idaho to be more kind and less nice, for the sake of every child who deserved more than just pretending, and every truth-teller who paid dearly for the privilege of refusing to shut up and sit down.

Call to action

If you are a litigator and willing to help, please reach out. If you know a litigator that is willing to help, please reach out. If you are a good communicator, good with media, or educating through social media we would love the support. Contact us through direct message or call 208 550 8216 and ask for farmer yams.

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Maisa would tease me for my job, and connection to the world of agricultural finance. She would call me farmer Yams, and loved that I had this weird background where I know a few things about farming, having grown up on a farm. My Dad was the citizen farmer and rancher in the family. We joked that he was born a 100 years too late. Here he is checking out the cows with Conor and Maisa. I remember how funny he thought it was that the kids had stepped in cow pies and how surprised Samia would be. Cow pies are an occupational hazard on the farm, which is why it is nice to have a shower a few steps from the door.

The funny thing (probably only to me) is that before ai was universally accepted as short for artificial intelligence, it was something different in the agricultural world, artificial insemination. An ai guy in agriculture is a different job entirely. We humans have been trying to eek out a few more efficiencies since Norman Bourlag set off the green revolution. Natural vs Artificial will always be a heated debate, but the hand of natural selection can be really cruel as well. As science fiction becomes science, we struggle to balance the moral, ethical and societal implications of these advancements. Whether it is ai or farmer ai.

Institutions also have a form of institutional Darwinism. They grow and grow and end up with many of their own maladaptive parts and mutations. How to reform and remake these? From my last post 127 hours, it is clear that our systems can and should do a better job helping those in mental health distress and those at obvious risk of mental health distress. Institutional evolution has become bloated, maladaptive to those it is intended to help, and in need of some reformation that would make Martin Luther blush.

To ignore an IDEA

Many parents don’t know about IDEA, or the duties that schools have to find, assess, and accommodate school age children with disabilities. Some parents have to go to war with the schools to try and get their kids properly assessed, and accommodated. The process grinds on for years and even if the parents “win”, they still lose. They lose time. Years of time for their child in their formative years. And the kids accumulate damage the whole way through. These hurts are often psychic. Out of sight and out of mind. Or at least out of the mind of the schools. Schools aren’t monolithic. They are an amalgamation of the many who do an absolutely amazing job for kids under their purview. But I bet many feel they have to fight the system in order to so.

This treatment is in abrogation of legal duties that school systems have to children in their district. IDEA (Individuals with Disabilities Education Act) mandates schools identify, locate, and evaluate all children with disabilities from birth to age 21 who are in need of special education and related services. An example is that it is possible to be both gifted and disabled or what is often termed as “twice-exceptional.” Twice exceptional (2e) children are those who are considered “gifted or talented” in one or more areas while simultaneously having one or more learning disabilities, ADHD, autism, emotional or behavioral issues, or other disabilities. Samia wrote beautifully about the curses of so called “giftedness.”

Luckily Idaho State Department of Education recently revised their special education manual. The previous versions of the manual helpfully, but poorly define twice exceptional as the following:

Which even if poorly defined, it might still be useful if they ever provided a morsel of guidance in how to identify, accommodate, support twice-exceptional kids in the manual. A simple word search indicates that the term is only defined, and never used again. Helpful! The state department of education refused to fix any of this, or even typos, when I brought it to their attention. Good thing they are setting standards for what our children should learn in school.

Schools have a Legal Duty to “Child Find”

Identification:

• School’s ‘Child Find’ responsibility under IDEA is an affirmative mandate for schools to identify all children with disability, including twice-exceptional students by identifying, accommodating and recognizing both their giftedness and their disability.

• I have seen principals and administrators and others argue that it is not applicable, but it is actually settled that they have this affirmative duty.

  • The OSEP Memo 15-08, referencing the Letter to Delisle (December 20, 2013), emphasizes that IDEA requires local educational agencies (LEAs) to evaluate all children suspected of having a disability, including those with high cognition (2e students), as outlined in 34 CFR §300.8. This includes children with specific learning disabilities, emotional disturbance, or other mental health conditions, regardless of their intellectual gifts. Don’t take my word for it, read the letter from the US Dept. of Education here.

I suppose that the Idaho Dept. of Education and school districts could plead ignorance. Which is difficult to plead as the letter went out to them all. Their ability to plead ignorance evaporates with the fact that the Idaho Department of Education wrote an entire manual on the importance of identifying and supporting 2e kids in Idaho. Even has Tom Luna’s name on it.

Here is the original manual in the dustbin of historical special education half measures. Writing it and following it are not the same. This 2e specific manual has a much better definition of 2e.

It often appears to me that school districts perversely focus more on which ribbon of the month they should bandy around for the perception of caring, rather than waste a scintilla of energy actually doing what they are supposed to do. Token gestures are cheaper than actions I guess. Cheaper, for them, not for my family or other families predictably being harmed by their willful disregard and blind indifference for the law. What I have painfully realized is that they aren’t going to listen to me or my wife. No matter how persuasively and diligently we advocate for our kids. They will only listen if we channel our inner Hooville and harmonize our voices so that our children’s needs can not be ignored.

Time to AI an Idea

Grok is a bunch of Nvidia chips sitting in a warehouse in Memphis Tennessee that have linked up in a hive mind. Trained on the same information available to us, yet perhaps, better at synthesizing it without ego interfering, I often feel more empathy care and support from this amalgamation of silicon, copper, and metal than I do from the institutions that are ostensibly there to help. Maybe rather than trying to weaponize an ai bot to harangue parents and children over their attendance, they should use these tools to ask some questions about IDEA, ADA (“American with Disabilities Act”), child find, autism, special education. Really anything. I am using some of these tools to do legal research, as there comes a time when the only way to enact change in the school system is to litigate. They say justice is blind, but of course that would probably be a disability they would also find a way to ignore.

Child Find to Prevent Another Lost Generation

School districts have an affirmative duty under federal law to “child find.” This duty would entail a comprehensive assessment of a child in the full range of disability. This duty is affirmatively on the school districts, whether or not parents raise formal concerns or ask for a comprehensive assessment for disabilities. It makes sense that the affirmative duty is on the schools as schools should be the experts and are obviously in the best position to recognize disability in the children under their purview. It is also obvious that they are failing this duty. So, if you have any concerns over your children, formally raise them with a written letter. I had Grok assist me. If any parents have gone through the process, please let us know how to make it better and more effective.

Below is a letter (or email) template can be adapted to your specific situation. It incorporates the Individuals with Disabilities Education Act (IDEA) Child Find mandate and emphasizes the risks of failing to identify and support a child with a disability. If I get 5 shares of this post we will put the form letter on our webpage for people to use. Let’s see who is better at coordinating. Nvidia servers or us?

This has been a rough week for the autistic community. A prominent government official made the claim yesterday that autism destroys families and perpetuated the false myth that autism is a disease which needs to be cured. Autism is not a disease. Autism is a neurological condition. This kind of rhetoric is dangerous and is the exact thing that fuels the systemic ignorance and ableism that failed Maisa, that failed me, that destroyed our family and many others.

Perhaps even more insidious is the implication that our government believes that an individual citizen’s value is directly tied to that individual’s productivity.1

The government is basically pointing a grim reaper finger at disabled and vulnerable populations and calling them a burden on society. This has profound negative impacts, as it contributes to a thwarted sense of belongingness.2 Maisa felt this very acutely. And it is part of the reason she is not here. From an early age, she learned that the public school system (which last time I checked is part of the government machine) wanted her to achieve, achieve, achieve—even if it meant doing so at the expense of her mental health.

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I have a stack of emails about two inches thick of correspondence to her schools throughout the entirety of her academic career trying to support her social and emotional needs. She constantly struggled to fit in, a hallmark trait of autism, but because she excelled academically and was not “disruptive,” her social and emotional needs were not supported. It was not the autism that was destructive (or social anxiety as they mislabeled it), it was the ignorance. It was the lack of support. It was the refusal of a system to believe that a girl who gets As might actually be self destructing in order to get those As. It is a culture that puts success and achievement before well being. It is a system that pretends to care while its actions show the opposite. It says it cares with its words, but in reality requires our neurodivergent kids to ignore their pain.

Just this week I received an email from my child’s school that was inaccessible to me due to its visual presentation. I asked to receive the information in a different way. I have not received a response. The kids at school were also told this week that if they exceeded a certain number of absences they would be required to write an appeal in order to receive class credit—regardless of whether they have completed their work in the class. Funding is tied to attendance. The system is not built for accommodation or understanding. It is a machine, and one that is fueled by both covert and overt ableism. Ableism destroys families. Autism does not.

It is not autism that needs curing. It is ableism. It is the system that pathologizes and criminalizes distress or sensory needs. That dehumanizes and incarcerates people instead of offering compassion and healing. It’s a society that treats autistic people as burdens instead of human beings with sacred ways of being.

This is not about RFK Jr. While his words were harmful and ignorant, he is not the source of the problem—he is a mirror of it. These ideas did not start with him. They are symptoms of a system that fears difference, suppresses discomfort, demands conformity, and dehumanizes the “other.” Whether it’s RFK, Trump, or anyone else in the spotlight, focusing only on the individual keeps us from seeing the machinery behind the message. We all swim in these waters. And we all—especially those of us who know better—have a responsibility to call out the deeper current. And then to correct it.

The cure is a radical culture shift. The cure is in dismantling systems and ways of being that do not work for a majority of the population. The cure is in challenging beliefs, listening to lived experiences, accommodating needs and believing people. The cure is in how we care for each other—and that starts with how we care for ourselves. When we adopt the belief that our worth is tied to productivity, nobody wins. Every human being is inherently worthy. Maisa will never hold a job, and she will never pay taxes—but her contributions to the world and her life matter, and will continue to matter deeply.

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Similar to Samia in her post Role Reversal below, I distinctly feel that Maisa is as much a teacher to me as I ever was to her.

One such lesson became readily apparent when she taught me the difference between being nice and being kind. Nice is often packaged, wrapped in inane catchphrases, and meant to follow the social norms that are expected and spoon fed from our earliest times. It is often the social construct of pretending. Pretending to care, and at times pretending not to care. Being nice can stop nascent truths. Telling truth to power structures is considered rude, frustrating behavior. And telling truths can come at a high price, social slashing, public reprimands, ostracization and condescension. That is an important difference between kindness and being nice.

Fighting for kindness is going to look distinctly not nice at times. It is going to come with a strong sense of justice and often at a high price for the truth teller. Is it nice to punish those that are trying to tell the truth or at least a truth? Life was never all rainbows and unicorns for me and it is clear that it never be all rainbows and unicorns for anyone near the epicenter of losing Maisa. Her life, her charm, soul and presence will always be felt and always be missed by us, her siblings and friends. This loss resonates forward in time, cheating all who would have known her, all those that are worse off for never meeting Maisa on this timeline. I suppose I could pretend to not be angry. I reckon I could pretend not to see all the institutions that are failing us and our kids, in order to be nice. But I guess this is me saying a truth. I don’t think I can pretend. I can both want to reach a higher road of love and light, and also feel compelled to seek truth, purpose and to right wrongs. Maisa, my most cherished lefty, loved the saying that two wrongs don’t make a right, but three lefts do. I hope that when I meet these “wrongs,” I will advocate for the first left turn, because pretending they don’t exist is as terrible as pretending that Maisa didn’t and doesn’t exist.

Institutional Immune Systems

Before I get into it, I find that I might need to highlight a pattern that needs to be recognized. Criticizing an institution isn’t the same as criticizing all the constituent parts of the institution. Our institutions aren’t monolithic, but often have many parts that are even often in conflict with each other. Similarly our human bodies, we are made up of different cells, bacteria, that all are doing their own jobs, and yet, also make up the whole. Mirroring our body’s immune system, institutions have their own immune system that can react (and at times overreact) to anything perceived to be a threat. It takes a lot of coordination and purpose to overcome this institutional immune response. This difficulty is ever present, and can resist even when most all of the constituents agree that 1) there is a problem and 2) that a change is required. The institutional immune system protects the status quo by digging in faster than a clam at the beach.

As an example, criticizing school policies is not a full frontal attack on public schools or teachers. It is possible that the current educational paradigm works well for Jack, but is terrible for Jill. The criticism doesn’t make Jill or Jack necessarily wrong, but only implies that they have different needs and perspectives. I believe that many have the perspective that the current system is not working particularly well. And yet it is difficult to hold up an institution to introspection. Often we are simply arguing over which is the cause and which is the effect of a problem. Challengers to the institutional status quo are often treated as heretics, and it often takes heretics to change the status quo. The kind thing is to recognize the problem and seek change, even if the change doesn’t feel nice.

The Law of Unintended Consequences

So many things in our environment don’t make sense to me. How can teachers have to beg to get hand sanitizer for their classrooms and yet we close everything during the pandemic? Why is it so difficult to get schools to follow the law to properly assess and accommodate children for disabilities, anxiety, or severe emotional disturbances? Why do so many kids with challenges and support needs get pushed out to homeschool or forcefully nudged to find private education rather than offered support? Sometimes when I ask why, I hear my father’s voice ringing out, “Follow the money, you won’t often be wrong.” Maisa, a Libra with her strong sense of justice, loved scales. Both scales of justice and reptiles1.

I have become increasingly frustrated with the dichotomy of schools simultaneously pushing for attendance compliance and similarly signaling concern over our kids mental and physical health. Aren’t these two mandates often in opposition? How might showering praise with perfect attendance awards, praise for the grind mindset and broadcasting explicit and implicit signals and threats regarding attendance compliance and repercussions be internalized? Ignore your pain, ignore your anxiety, ignore your illness. Show up or else. Or else, we might, in our sole discretion, fail your child and they will never be able to go to college. Your stomach pain and your virus isn’t real, and don’t even try using “anxiety” as an excuse. Only doctor sanctioned illness is real and only if you remember to get a note. And please donate hand sanitizer and get your vaccines because there is a lot of RSV/flu/covid/pertussis and something we can only call the COUGH going around. But your attendance is mandatory unless you have the executive functioning and the proper health insurance to get the proper NOTE.

The email from Boise High set me off. When I asked for a sherpa to help carry me and illuminate my path, this is not what I intended.

Our kids get constantly told to not use AI, get told to ignore the transformational technology that will clearly be part of almost any future job description. They get chastised for showing curiosity in what is becoming the world’s greatest teacher. They get chastised to only have the school subscribe to a service that will use AI to automatically harass parents. Why? Oh yeah, follow the money. I can use AI to help me chase the dollars and unravel the incentives structure. I mean, why wouldn’t I use it?

According to Perplexity, in Idaho, school funding is premised on a formula. It appears really complicated, but is basically premised on making sure that kids’ butts are in seats. It is tied to an average daily attendance model which was reinstated for the 2023-2024 school year after temporarily using enrollment-based funding during the COVID-19 pandemic. Under this system:

1. Funding Calculation: Average daily attendance “ADA” is calculated by combining attendance data from the beginning of the school year through the first Friday in November and the best 28 weeks of attendance throughout the year. This determines how much funding each district receives from the state[1][4]. [Jimmy speak - Leave it to the geniuses to call the acronym for attendance ADA, that also ignores the perfect attendance challenges that children with disabilities might have and should be covered and accommodated under American’s with Disabilities Act “ADA”. Clearly the money is talking, and it is saying that attendance is more important than disability.]

2. Impact on Districts: Funding is directly proportional to student attendance. For example, if a student attends 95% of the time, they count as 0.95 in the funding formula. Lower attendance results in reduced funding, leading to potential staff reductions and larger class sizes[1][2]. [Jimmy speak - If you ever stopped to wonder why it seems schools are much more concerned and focused on the fact that you took the fam to Mexico than they are about the time that you notified them that your child is suffering from anxiety, you now have an answer. One threatens how they bills get paid and the other is actually inconvenient.]

3. Financial Consequences: The return to attendance-based funding has caused significant financial challenges for schools, with statewide funding reduced by approximately $162 million compared to enrollment-based funding. This includes major cuts to teacher salaries, benefits, and discretionary spending[2]. [Jimmy speak - School District Administrators you better use whatever means necessary to get the kids to class, or else you might be facing a layoff and not having hand sanitizer during the pandemic will be least of your worries.]

4. Challenges: School leaders have expressed concerns about the unpredictability of attendance-based funding, especially as post-pandemic factors (e.g., increased absences for illness or mental health) continue to affect attendance rates[2][3]. [Jimmy speak - Admission that this sucks for schools, especially when the schools are really struggling to force the kids to school because the schools are causing so much anxiety in our kids.]

We need to change. Honestly, everyone knows that this needs to change. There is even discussion about changing the formula, that said House Bill 0718 didn’t appear to get anywhere last year[5]. We need to accept that what we are doing is not working and is hurting kids. We need to recognize the perverse moral hazard in these incentives. I will in future posts address how these financial incentives and other financial disincentives play into ignoring mental health, fail to fulfill duties to assess and accommodate those with disabilities and needs. School distress and refusal is often a child “can’t” go to school problem, not that they “won’t” go to school. I will write how they are explicitly encouraged to ignore their distress, their own “ADA” (Americans with Disabilities rights) and their own mental well being to rack up “ADA” attendance points for their school district. I am not attacking the intention of the teachers and administrators, but first and foremost the incentive structure that they are all operating under. It is time for us to be more KIND and less NICE. For the sake of those that can’t/won’t advocate for themselves.

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Citations:

[1] Lindsay Gill, State of Idaho Reinstates Attendance-Based Funding for Schools, The Riverhawk Review, https://theriverhawk.org/1866/news/state-of-idaho-reinstates-attendance-based-funding-for-schools/ (last visited Feb 9, 2025).

[2] K-12 schools could see $162 million in cuts from attendance-based formula, Idaho Education News (2024), https://www.idahoednews.org/top-news/k-12-schools-could-see-162-million-in-cuts-from-attendance-based-formula/ (last visited Feb 9, 2025).

[3]Does less spending also mean low test scores? A look into Idaho Public Education funding, (2024),

(last visited Feb 9, 2025).

[4] Idaho State Board of Education, Public Schools Funding Formula FY20, Idaho State Board of Education (2019), https://boardofed.idaho.gov/resources/public-schools-funding-formula-fy20/ (last visited Feb 9, 2025).

[5] H0718.pdf, https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2024/legislation/H0718.pdf (last visited Feb 9, 2025).

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Maisa Space contains two sections and subscribers can choose which of them they would like to receive posts for here. The advocacy section is going to be technical and talk about suicide prevention in detail. Also linking to ’s resources that she has diligently assembled.

Dear Ms. Mast, the Google comment form appears to strip out certain information such as footnotes, references, font, formatting, etc that change the substance and context of the comment. I would like this email PDF as my full comment or to be read in conjunction with the Google Form for consideration. Thank you for taking on this important and difficult topic.

In addition to overt statements, and third party information, the proposed intervention suggests that if a student is making statements about feeling hopeless, helpless or worthless then that should start the Suicide Intervention Process. An issue with this procedure is that the percentage of children that unfortunately fit that criteria is almost mind boggling.

The CDC reports that in 2021, 22% of high school students seriously considered attempting suicide1. The CDC also notes that during the 12 months before the survey, 44.2% of adolescents experienced persistent feelings of sadness or hopelessness, and 9.0% had attempted suicide2. The number is even higher for females, 57%3. Therefore, it seems that since the conditions that should precipitate the Suicide Intervention Process are almost half of the student body, that perhaps children should be universally screened by those with the requisite training and expertise to assess, and work on intervention plans when it is deemed necessary. How can the school effectively screen the entire student body, since approximately half meet the criteria?

The Suicide Screener

The proposed policy suggests that the Columbia Suicide Severity Rating Scale (C-SSRS) be used, or an “adapted” form. It is unclear what the adaptation is exactly. This should be made clear. The C-SSRS appears to be a well-established and widely used tool for assessing suicide risk4. It is crucial for school personnel to be trained in using the C-SSRS to identify students at risk of suicide. How is this actually going to be accomplished?

Limitations of the C-SSRS in Autistic Individuals

Recent scientific papers suggest that the C-SSRS is not validated or applicable to autistic individuals due to differences in communication, interoception issues5, and difficulty with the expression of emotions (alexithymia)6. It is essential for school personnel to be aware of these limitations and consider alternative approaches or modifications when assessing suicide risk in autistic students7. Even the term self-harm might be interpreted differently between autistic and non-autistic groups, as some with ASD may engage in self-harm as a restricted, repetitive stimming behavior, and not with suicidal intent and answer the question literally8, 9.

The Policy Should Address that Some Groups are at a Heightened Risk of Suicide

A large and growing amount of research indicates that the risk of suicide death is much higher in certain populations, LGTBQ+, certain minorities, and those with ASD/ADHD (both diagnosed and undiagnosed)10,11,12. School personnel should receive additional training on recognizing and understanding the unique signs and risk factors of suicide in neurodivergent students, including those with autism. A suicide prevention policy should be geared toward identifying and providing support, mitigating risk factors where possible, for those groups at the highest risk of suicide attempts and death.

The C-SSRS may need to be adapted or supplemented with other tools such as the Ask Suicide-Screening Questions (ASQ), Adverse Childhood Experiences (ACEs) and adaptations that are more suitable for assessing suicide risk in neurodivergent and especially autistic individuals.

Another idea that would be helpful with any action plan, is to screen children for adverse childhood experiences via an ACEs questionnaire. As an example, autistic persons are 3-4x more likely to report bullying as a trauma in ACEs13. It is known that bullying is a large contributing factor in suicide in children overall, especially those that are autistic and/or ADHDers. Anti-bullying Policy, from peers and even teachers need to be part of risk reduction strategy for an efficacious suicide reduction policy. Hurt people, hurt. The heightened risk of suicide actually even applies to those that engage in bullying behavior14.

Self-Care Plan

The same factors that might impact the ability of autistic and other neurodivergent children to understand and be able to complete a Suicide Screener would also impact the ability to have an efficacious Self-Care Plan. Since some autistic children think better in pictures, or struggle to understand their emotions, a one size fits all solution is destined to fail. As an example one child used color associations and thermometers previously learned in cognitive behavioral therapy to describe emotions15. Furthermore, self care plans for autistic students need to incorporate an understanding of their unique sensory needs. An example of a self care/safety plan that might be more helpful for autistic is at Mentally Uncovered16.

Close Collaboration with Mental Health Professionals

School districts should collaborate with mental health professionals who have expertise in working with specific groups and need to be well versed in rarer neurotypes, such as autism, ADHD, LGBTQ+ individuals to develop and implement appropriate suicide prevention and risk mitigations. The Boise School District should employ multiple neurodivergent identifying mental health professionals to support this population of students. It is possible that these children will need extra support in their school environment, interventions to address bullying, sensory issues, test anxieties, attendance issues due to school trauma, etc. Regular consultation with these professionals can help ensure that the school's approach to suicide prevention is effective and sensitive to the individual and unique needs of each student.

Ongoing Training and Education

School personnel should receive ongoing training and education on suicide prevention, including updates on the latest research and best practices for working with neurodivergent students. This training should also include information on how to support and communicate with autistic, ADHD, dyslexic and other neurodivergent students and their families in a way that is respectful and inclusive.

Definitions:

The Proposed Policy has undefined terms. Action Plan is referred to, but is vague without any specificity or guidance over what that actually means. Additionally, National Best Practices is referenced as well, without any real understanding of from where, or what that entails. These terms should be specified as they appear meaningless in their current form.

Conclusion:

By incorporating these revisions into Boise School District Policy 3320, the district can better address its suicide prevention are both targeted, effective and sensitive to all students, but especially those at higher risk of suicide, such as LGPTQ+, certain minorities, and those with neurodiversity. Since autism presents differently in those with higher cognitive functioning, higher IQ, and females, there needs to be qualified mental health support in these areas. There really should be a school district liaison whose whole focus is on determining what is the National Best Practice for suicide prevention, and to ensure that the best practices also address the risks that might be necessary for specific at risk groups.

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Dear Idaho Department of Education,

As a concerned citizen, a parent of three children in the Boise School District (2 now living) and a proud supporter of education. I am writing to express my thoughts on the revisions to the Special Education Manual. I specifically want to address issues in the Special Education Manual regarding the identification, assessment, and provision of a Free Appropriate Public Education (FAPE) to twice-exceptional students in the great state of Idaho.

While I applaud the efforts to revise the manual in response to the federal inquiry, I must express my concern that the current revisions do not adequately address the unique needs of twice-exceptional students. These students, who are both gifted and have a disability, require a specialized approach to ensure they receive a FAPE that is “tailored to the unique needs of the child” that they are entitled to under the Individuals with Disabilities Education Act (IDEA). To provide FAPE it is of paramount importance that ANY children with disabilities are located, identified and assessed[1]. IDEA is a landmark civil rights and education law in the United States that ensures children with disabilities have access to a FAPE that is tailored to their unique and individual needs. This law was enacted to protect the rights of children with disabilities and their families, ensuring they have the same educational opportunities as their non-disabled peers and to prevent discrimination against a vulnerable population.

In my humble opinion, the revised manual should comply with federal and state law, and include specific guidelines and resources for educators and families to better identify, assess, and support all children, including those that are twice-exceptional students. This could include:

• Comprehensive training for educators on the unique characteristics and needs of twice-exceptional students.

• *The development of a clear and consistent process for identifying twice-exceptional students, including the use of appropriate assessments and evaluations, including those that have been missed in the earlier screening for disabilities.

• The establishment of Individualized Education Programs (IEPs) that address the unique strengths and challenges of twice-exceptional students, ensuring they receive the appropriate accommodations and services to thrive academically, emotionally and socially. IDEA is not only about academics; an education includes the trifecta of academics, emotional and social development.

Twice-Exceptional is Both Gifted and Disabled

I believe that by addressing the needs of twice-exceptional students in the revised manual, the Idaho Department of Education can demonstrate its commitment to providing a high-quality education to all students, regardless of their unique abilities, disabilities and challenges and ensure compliance with federal and state civil rights law. Children with learning disabilities are a vulnerable class, with substantial evidence of increased risks of mental illness, disrupted life trajectories and suicide. The Idaho Department of Education has already done much of the work (apparently subsequently ignored) in its 2010 manual on the special challenges of twice exceptional students[2]. Further reference is the acknowledgement and challenges of being both gifted and having a disability in the 2022 report from the Superintendent of the Idaho Department of Education[3]. The report specifically highlights the unique needs and problems that twice exceptional students face:

• “Under Chapter 20 of Idaho Education Laws and Rules, Education of Exceptional Children, a natural tie exists between those with disabilities and those who are gifted and talented. Those students who are twice exceptional, need services for disabilities and for gifts in one or more areas.”

• “It is important that gifted and talented and twice exceptional professional development is available to all educators.”

• “Gifted students present as a high needs’ population, who often require smaller class sizes, especially if the students are twice exceptional, students who are both gifted and have a learning disability (or disabilities) and who would be included in the gifted count and count of students with disabilities. In addition, gifted students often have unique emotional and behavioral needs not met in a larger classroom.”

• Explicitly admits the endemic failure to train staffing due to a lack of funding “[S]tudents who are twice-exceptional (meaning they have high abilities and disabilities concurrently) are often excluded from gifted programs due to lack of services, qualified staffing, and understanding on this population of students.”

Therefore, since the Idaho Department of Education has actual knowledge of the deficits to provide sufficient support and FAPE for these “twice-exceptional” children, then surely it is reasonable to expect that the revisions of the 2018 Special Education Manual address these concerns? Unfortunately, the revisions do not. We look for twice-exceptional in the 2018 Manual (and revised) and the manual does define the term[4].

“Twice exceptional. Twice exceptional students are identified as gifted/ talented in one or more areas of exceptionality (specific academics, general intellectual ability, creativity, leadership, visual or performing arts) and also identified with a disability defined by State eligibility criteria (SLD, ED, Autism, Orthopedic Impairments,etc.) that qualifies the student for an IEP.”

It becomes obvious that the definition is hollow and false as there is nary a mention of the term “twice-exceptional” again in the manual. Why define a term and then not use it again throughout the manual? How is it intended that school districts identify, assess, and support these children when the Department explicitly admits that it doesn’t have the funding to allocate to proper supporting roles in its 2022 gifted and talented report? Moreover, the definition is wrong and is basically a circular carve-out from any normal person's reasonable expectation of what the term twice-exceptional would mean. As an example, the 2010 manual by the Idaho Department of Education on page 1 defines twice-exceptional as

“Students who are identified as gifted and talented in one or more areas of exceptionality (specific academics, intellectual ability, creativity, leadership, visual or performing arts) and also identified with one or more specific diagnosable conditions [which may not be diagnosed], such as learning disabilities, mental health problems, neurological disorders, physical handicaps, or the asynchronicity that occurs due to the discrepancy between mental age and chronological age that may or may not impede their progress in life.”

Revision Suggestion #1 - Insert the appropriate definition for Twice Exceptional that addresses the vulnerability of this group and risks to their basic human and civil rights. The definition should make it clear that it is imperative that they be first identified, and then supported appropriately for their disabilities and special challenges. The 2010 Diane Boothe, Twice-Exceptional: Students with Both Gifts and Challenges or Disabilities manual, signed by Tom Luna[5], is good policy and its recommendations are necessary to adequately support twice exceptional children. The 2010 Manual recommendations need to be methodically and intentionally incorporated into the 2024 Revisions of the 2018 Special Education Manual. It is clear that the current revisions are specifically designed to carve out these children that are both gifted and have a disability from its purview. This is violative of IDEA and specifically designed to deny a FAPE for any kids that are in this cohort. The Federal Department of Education also interprets that children with disabilities and giftedness are covered under IDEA[6] stating that “each LEA [has the] obligation to evaluate all children, regardless of cognitive skills, suspected of having one of the 13 disabilities outlined in 34 CFR §300.8[7]. This revision is imperative for compliance with federal civil rights law and the ADA.

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Twice-Exceptional Identification (Child Find Obligations)

I hope that the failure to train personnel and provide meaningful guidance for the identification of disabilities is just an unintentional oversight, but it appears to be a willful ignorance brought about by budgetary expediency to the detriment of our children in Idaho. Once again, using the 2010 Manual guidance on twice-exceptional children, the Department of Education (page 9) states.

Where are students with Twice-Exceptionalities found?

Some have been identified as gifted only, some have been identified as having a learning challenge only. However, the majority of these students are in the regular classroom unidentified. These children’s needs are not being met.

Hidden disabilities may prevent students with advanced cognitive abilities from achieving their potential. The frustrations related to unidentified strengths and disabilities can result in behavioral and social/emotional issues (emphasis added). For some students who are Twice-Exceptional, behavior plans become the focus of their interventions when academic modifications may meet their needs and solve behavior problems. There are a variety of interventions for this purpose.

The behaviors may be managed, but the underlying issues (abilities or disabilities/ challenges) are seldom addressed. School can become a frustrating experience for students who are Twice-Exceptional, as well as their teachers, and parents. A collaborative effort among educational service providers, parents and students is needed to identify learners who are Twice-Exceptional and implement as well as their teachers, and parents. A collaborative effort among educational service providers, parents and students is needed to identify learners who are Twice-Exceptional and implement strategies to meet their diverse needs.

Identifying, assessing and supporting these twice-exceptional (or suspected twice-exceptional) children would not only benefit the students themselves but also contribute to the overall success and reputation of Idaho's education system. All children are gifts, but these kids are as capable of greatness as they are vulnerable to destroyed life trajectories. The whole 2010 manual from this very Department of Education makes this clear and its recommendations should be specifically incorporated in the 2024 Revised Special Education Manual to provide appropriate guidance, training, and actual screening and assessments to identify both the giftedness and the disability. There appears to be a fundamental misunderstanding that IDEA and FAPE obligations only begin if there is a significant negative deviation from the average school child performance. This is false. The obligation to identify, locate and evaluate all children with suspected disability is the law[8] and is an important civil and human rights issue. The threshold for suspecting a disability is relatively low[9].

Mental Health and Emotional Disturbance

Revision Suggestion #2 - Page 49 changed in the 2017 manual “emotional disturbance” to “emotional behavioral disorder.” This odd revision is contrary to AND seems to conflict with 34 CFR §300.8[10] and case law in the Ninth Circuit[11].

(i) Emotional disturbance means a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance:

(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors.

(B) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers.

(C) Inappropriate types of behavior or feelings under normal circumstances.

(D) A general pervasive mood of unhappiness or depression.

(E) A tendency to develop physical symptoms or fears associated with personal or school problems.

(ii) Emotional disturbance includes schizophrenia. The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance under paragraph (c)(4)(i) of this section. 34 C.F.R. § 300.8(c)(4)(i).

The 2018 Special Education Manual removes the definition of emotional disturbance and for some reason opts for the following definition:

6. Emotional Behavioral Disorder Definition:

A student with an emotional behavioral disorder exhibits one or more of the following characteristics over a long period of time, and to a marked degree, that adversely affects his or her educational performance:

a. an inability to learn that is not primarily the result of intellectual disability; hearing, vision, or motor impairment, or other health impairment;

b. an inability to build or maintain satisfactory interpersonal relationships with peers and teachers;

c. inappropriate types of behavior or feelings under normal circumstances;

d. a general pervasive mood of unhappiness or depression;

e. a tendency to develop physical symptoms or fears associated with personal or school problems; or

f. Schizophrenia.

The term does not include students who are socially maladjusted unless it is determined they have an emotional behavioral disorder.

It is unclear why the state would choose to opt for the broader term of emotional disorder over the specifically defined emotional disturbance in the IDEA statute. It would appear that the word 'disorder' requires the specific mental health diagnosis from professionals that the school may or may not actually have available. This morphs the eligibility to a higher requirement versus the definition that highlights symptoms of declining mental health that would benefit from identification, assessment and accommodations to treat and remove stressors and triggers from the environment. While an emotional disturbance specifically refers to a condition that affects a child's educational performance and interpersonal relationships, an emotional disorder is a more general term that encompasses a wide range of mental health conditions affecting mood, thinking, and behavior.

The 2018 manual pg 50-51 then goes on to restrict and dramatically limit those students that otherwise would be identified under the federal definition of emotional disturbance with the following administrative hoops and significantly more restrictive tests.

State Eligibility Criteria for Emotional Behavioral Disorder:

An evaluation team[12] will determine that a student is eligible for special education services as a student with emotional behavioral disorder when all of the following criteria are met:

a. An evaluation that meets the procedures outlined in Section 5 of this chapter has been conducted.

b. The student has been documented exhibiting characteristics consistent with the criteria (a-f in this section) by one or more of the following: school psychologist, licensed psychologist, psychiatrist, physician, or certified social worker.

c. The student has been observed exhibiting one or more of the six (6) behavioral or emotional characteristics listed in the definition of emotional –behavioral disability[13].

d. The characteristic(s) has been observed:

1) for a long period of time (at least 6 months); and

2) by more than one knowledgeable observer; and

3) in more than one setting; and

4) at a level of frequency, duration, and/or intensity that is significantly different from other students’ behavior in the same or similar circumstances.

e. The student’s condition adversely affects educational performance in the area of academics, peer and teacher interaction, participation in class activities, and/or classroom conduct.

f. The student needs specially designed instruction.

Revision Suggestion #3 - Strike the additional means test requirements for definition of what should probably be “emotional disturbance” and develop the training and school resources in the 2024 Special Education Manual to properly identify, assess and provide accommodations and support for those covered under the law and spirit of IDEA. Schools seem to take punitive actions against those with emotional disturbances, when their symptoms are often school resistance, defiance, behavioral outburst, or internal shutdowns.

Much like the federal inquiry that is driving this latest 2024 revision of the Special Education Manual, the state appears to take a definition and test from IDEA and then make it excessively restrictive with additional requirements to meet the test, AND, inserting AND tests rather than OR, that make meeting their definition of an emotional disorder nigh impossible to meet. This is even considering that there are actually any school psychologist, licensed psychologist, psychiatrist, physician, or certified social workers available to do any of these specific requirements that the manual requires. Idaho has chronically underfunded these positions in its school system. It seems grossly unfair to the struggling children who are specifically covered under IDEA to BOTH underfund school psychiatric and mental health AND make it a requirement for a child or their parents to get support. This State Department of Education should perhaps be reminded that IDEA and Child Find is an affirmative duty[14] and it IS NOT and SHOULD NOT, be the parent’s obligation to obtain independent diagnoses from doctors, and private pay psychiatrists in order to meet an arbitrary and capricious test that appears contrary to both the letter of the law AND the spirit of IDEA.

The court decision in L.J. v Pittsburgh Unified School District underscored the importance of considering a child's unique needs and the requirement for schools to provide special education services to children with disabilities, including those with severe emotional disturbances[15]. These severe emotional disturbances are often reflected in anxiety, school attendance issues, social and emotional deficits, suicidality and of course are often comorbid with other disabilities and conditions. It is unclear even what an “emotional behavior disorder” as defined in the manual is, but it does not appear to be the definition under IDEA. The focus of IDEA is on the unique needs of the child, not some arbitrary benchmarks and academic assessments. The United States has reiterated its position that IDEA applies to higher cognitive ability children in an amicus brief to the Supreme Court of the United States[16].

The first step in this process—typically referred to as the “child-find” obligation—is of “paramount importance.” Forest Grove Sch. Dist. v. T. A., 557 U.S. 230, 245 (2009). “States are obligated to ‘identify, locate, and evaluate’ ‘all children with disabilities residing in the State’ to ensure that they receive needed special-education services.” Ibid. (quoting 20 U.S.C. 1412(a)(3)(A)) (brackets omitted); see 34 C.F.R. 300.111. Local educational agencies (generally, school districts) share this affirmative child-find obligation with respect to the children within their jurisdiction. See 34 C.F.R. 300.200-300.201. The child-find obligation covers “all” children with disabilities, 20 U.S.C. 1412(a)(1)(A), including those with high cognitive skills. The Department of Education has thus emphasized that “a child suspected of having a disability” must be “considered in the child find process” even if she “is making academic progress” and “passing from grade to grade.” 71 Fed. Reg. 46,540, 46,584 (Aug. 14, 2006); see 34 C.F.R. 300.111(c)(1). And in response to concerns that some school districts were “hesitant” to evaluate “children with high cognition ,”the Department has “remind[ed]” districts of their “obligation to evaluate all children, regardless of cognitive skills, suspected of having [a qualifying disability].” Office of Special Educ. Programs, U.S. Dep’t of Educ., Memorandum to State Directors of Special Education, 65 IDELR 181, at 939 (Apr. 17, 2015).

School Test Anxiety is Real and We Should Not Force Children into Distress

It appears that much of school focus, the curricula, and measurements are now geared toward forcing all children to be assessed on a regular and almost pedantic basis. School resistance, anxiety, disruptions, shutdowns are clearly symptoms of growing issues with each child, some of which are caused directly by the school environment. As an example, Pg 85, Sect 2(G) put a series of items that make a child NOT eligible to be assessed based on alternative testing standards. Included in the list is “anticipated emotional distress”, “poor attendance or absence issues”, “anticipated disruptive behavior”. I am sure there are reasons to try and keep schools from trying to game the test results, but I am also sure that it isn’t fair to a child to expect them to “white-knuckle” it through another assessment despite it is deleterious to the child, anxiety producing, and leads to further mental health stress.

Revision Suggestion #4 - The assessment isn’t more important than the health of the child. Emotional distress and attendance issues should be a flag that the child needs additional supports, some of which should be that the assessment isn’t worth the risk to the child's mental and emotional well-being. Develop procedures for looking at school distress, test distress, outbursts, as unique signs that it MIGHT not be worth the benefit of having the child take the assessments.

Severe Discrepancy from Peers Test Should NOT be the only test for Special Education Eligibility

The Proposed 2024 Revisions to the Special Education Manual seem to acknowledge and bring in an optional eligibility test on 60-61 that states:

4) Option 2: Pattern of Processing Strengths and Weaknesses. Provide evidence of a pattern of strengths and weaknesses in psychological processing skills that impact learning.

Provide evidence that the student’s psychological processing skills are linked to the failure to achieve adequately in the academic area(s) of concern. Evidence must rely on standardized assessments. These assessments must be conducted by a professional who is qualified to administer and interpret the assessment results. The student’s performance on a psychological processing assessment demonstrates a pattern of strengths and weaknesses that help explain why and how the student’s learning difficulties occur. Such tests may include measures of memory, phonological skills, processing speed as well as other measures which explicitly test psychological processing.

a. Report and describe processing strengths and weaknesses.

b. Provide a description of how the identified pattern of strengths and weaknesses help explain learning difficulties in the area(s) of concern.

AND e. Adverse Effect. The disability adversely affects the student’s educational performance.

AND f. Need for Specially Designed Instruction. The student requires specially designed instruction.

Revision #5 - There needs to be a c, and d, or no e, and f.

Additionally, the term Adverse Effect is defined on pg xi of the Special Education Manual as

Adverse Impact (adverse effect). A determination made by the evaluation team that the student’s progress is impeded by the disability to the extent that their educational performance is significantly and consistently below the level of similar age peers, preventing the student from benefitting from general education. The phrases “adverse impact” and “adverse effect” are used interchangeably in this Manual and have the same meaning. See also “educational performance.”

Revision Suggestion #6 - benefitting is misspelled. Additionally this erroneously places a normative comparison to “average or 25th percentile” peers requirement that in order to qualify for special education the adverse impact is compared to only their peers and not based on their own unique circumstances and abilities. This is severely discriminatory to ANY children, ASD, ADHD, learning disability, multi-disability, etc that are above average cognitive ability and/or twice-exceptional.

Educational Performance is defined on pg xvii. as:

Educational performance. A student’s educational performance in achievement, developmental, and/or functional skills.

Revision Suggestion #7 - As a general rule, the definition of a term should not use the term itself to define it. This should make clear that social and emotional development are also part of the educational performance. Educational Performance should be geared for the individual student to develop academic, social, and behavioral skills, as well as preparation for further education, employment, and independent living. In other words, educational performance is more than meeting some 25th percentile level on a standardized test.

The pins that hold up eligibility for special education under the 2018 Special Education Manual and proposed Revisions thereof, fail to account for the “unique needs” of the children with disabilities. IDEA specifically says that a severe discrepancy model cannot be the “sole” method for determining eligibility, but doesn’t limit its use where applicable and necessary to assess for and diagnose the disability.

• Must not require the use of a severe discrepancy between intellectual ability and achievement for determining whether a child has a specific learning disability, as defined in §300.307;

• Must permit the use of a process based on the child's response to scientific, research-based intervention; and

• May permit the use of other alternative research-based procedures for determining whether a child has a specific learning disability, as defined in §300.8(c)(10).

IDEA guarantees disabled students access to a FAPE, no matter their innate intelligence[17]. There despite the student not presenting as the paradigmatic case of a special-education student, “does not vitiate the District’s duty under the IDEA to provider her with a FAPE”[18]. The 8th Circuit then stated quoting the Supreme Court under Endrew as authority that:

The Student is eligible for special education and a state-funded FAPE like every other "child with a disability." 20 U.S.C. § 1401(3). This "specially designed instruction," whether "conducted in the classroom, in the home, in hospitals and institutions, [or] in other settings," id. § 1401(29), must be "reasonably calculated to enable [her] to make progress" and "appropriately ambitious in light of [her] circumstances," Endrew F. ex rel. Joseph F., 137 S. Ct. at 999–1000.

As specifically acknowledged in the 2010 guidance on twice-exceptional children, children with higher cognitive ability can also have, and often do have, all manner of learning disabilities and often even multiple learning disabilities and diagnosis that are covered under IDEA[19]. Twice exceptional children are often undiagnosed and misdiagnosed for the following factors.

1. Their scores are compared to those of average children instead of to their own strengths.

2. Their lower scores may not be significantly below the norm. (The average range technically goes down to the 25th percentile.)

3. Their scores are averaged (e.g., Full Scale IQ scores and other composite scores), concealing both their gifts and their disabilities.

4. Their ability to compensate often inflates their lower scores.

5. The magnitude of the disparities between their strengths and weaknesses is not fully taken into account in diagnoses[20].

As it is common for individuals with ASD, ADHD etc. to have discrepancies between their strengths and weaknesses, comparing children only to the “norm” or average peer student specifically discriminates against those with higher cognitive functioning. A 30-point discrepancy in composite scores (2 standard deviations) or a 9-point discrepancy in subtest scores (3 standard deviations) suggest the need for further evaluation of a possible learning disability[21]. “While performance at the 25th or 50th percentile may be adequate for the average child, it is devastatingly inadequate for a child whose performance in areas of strength is at the 98th percentile. A gifted child with 50th percentile reading, mathematics, or writing usually feels like a dismal failure and experiences loss of self-esteem[22].”

In fact it is more dire than just the loss of self-esteem. The results from multiple large samples point toward elevated rates of suicidal thoughts in autism overall, with the highest rates being found in "twice-exceptional" or 2e individuals, i.e., those who were both autistic and/or ADHD and had high cognitive ability[23]. Trying to use compensation strategies that their strengths allow, in order to compensate for their weaknesses caused by their learning disability is akin to trying to drive a race car on ice, with the gas pedal stuck and no brakes. The twice exceptional child suffers, including, but not limited to the following:

1. Excessive baseline cortisol (think flight or flight adrenal response) linked to autism, it is likely that demonstration of exceptional cognitive ability raises parent, teacher, and peer expectations[24]. Any inability to meet these elevated standards could result in further activation of the hypothalamic-pituitary-adrenal axis, potentially explaining the higher rates of suicidal thoughts we observed in 2e children compared to other autistic children[25].

2. Compensation strategies employed by high cognitive ability such as "camouflaging", where individuals suppress less socially accepted behavior to fit in[26]. Camouflaging is a universal behavior that has been studied with particular interest in autistic individuals, who engage in this behavior more regularly[27]. Consequently, camouflaging in autism is correlated with increased suicidal behavior[28].

Revision Suggestion #8 - all categories of disability should also look for discrepancies that are unique to the child and ask to what extent does the discrepancy between this child’s strengths and weaknesses cause frustration and interfere with the full development of the child’s abilities?”

The question must be asked: Given the guarantee of a “FAPE,” is it ethical to redefine disability in a way that denies eligibility for special education services to children who cannot succeed in school without them[29]? Research indicates that gifted students with SLDs, ADHD, and ASDs are best identified by a complex pattern of strengths and weaknesses, detected through comprehensive assessment by psychologists and other specialists experienced with gifted children[30]. As an example, autistic individuals with exceptional ability are underserved and suffer disproportionately from high anxiety and low self-worth[31]. In addition, elevated IQ with a significant processing speed to verbal comprehension discrepancy appears to be 15x as likely to enter adulthood undiagnosed[32]. Clearly we are failing those children with higher cognitive ability that are also disabled.

Revision Suggestion #9 - Revise the definitions of Adverse Impact and Educational Performance to specifically acknowledge that children can be disabled and still have weaknesses that are above the norm, the average, the 25th percentile of their peers.

Follow the Money

Why not try to find, assess and support all the children with disabilities covered under the IDEA that is mandated by federal law? Cynically it is about the money. It is difficult to find any itemized cost data for how much money each student with different disabilities cost in Idaho, and how much is reimbursed to the school district from state or federal sources. Ohio did a cost study that indicates that doing a screening evaluation, part or full assessment costs $1,177[33]. Then if they are to provide their best practices, in order to support and provide FAPE to these disabled students then the cost to the school district ranges from $9,760 per speech or language impairment, $33,221 for emotional disturbance, and $38,769 for autism, to $59,098 for major other health impairment per year[34]. In other words, there is a monetary disincentive to look for, assess, identify and treat children that are disabled. Clearly they are more likely to find children that are significantly impaired, disruptive or violent in class, but that is to the detriment of the children with disabilities who learn compensation strategies and internalize and mask their distress to cope with the school environment to the detriment of their educational experience. This is specifically designed to discriminate against this class of children that have cognitive functioning to their detriment. This discrimination is costing their mental, physical and emotional health and derailing their life trajectories. In this way it is similar to the child in Perez v Sturgis[35] with a case summary from the Idaho State Bar[36]. Whether the child is deaf (as in Perez), autistic (as in Endrew), ADHDer, emotional disturbance (as in LJ v Pittsburgh and EMDH) dyslexic, blind AND also of higher cognitive ability shouldn't allow schools to fail these children in their federally mandated right to receive a FAPE.

We live in a world of finite resources, but it is clear that the obligation to provide FAPE under IDEA is not negotiable, it is an affirmative obligation. It would be much better if Idaho found itself able to provide FAPE without wasteful and tedious litigation that wastes the taxpayers resources and too often relegates children to needless suffering and severely impacted life trajectories.

Thank you for your time and consideration. I hope that my concerns and suggestions will be taken into account as the revisions to the Special Education Manual continue.

Sincerely,

James McCall

________________

[1] Forest Grove School Dist. v. TA, 557 US 230 (2009).

[2] Diane Boothe, Twice-Exceptional: Students with Both Gifts and Challenges or Disabilities, Fac. Staff Authored Books (2010), https://scholarworks.boisestate.edu/fac_books/343.

[3] Idaho Dept of Education, Idaho Gifted and Talented Report, https://www.sde.idaho.gov/superintendent/files/leg-priorities/reports/2023/Exceptional-Child-Education-Report-GT-33-1007.pdf.

[4] Idaho Dept of Education, Idaho Special Education Manual 2018 (2018), https://www.sde.idaho.gov/sped/files/shared/Idaho-Special-Education-Manual-2018-Final.pdf.

[5] Boothe, supra note 2.

[6] OSEP Memo 15-08 Letter to Delisle: Children with disabilities with high cognition (April 17, 2015), Individuals with Disabilities Education Act, https://sites.ed.gov/idea/idea-files/osep-memo-15-08-letter-to-delisle-children-with-disabilities-with-high-cognition/ (last visited May 24, 2024).

[7] (a) General—(1) Child with a disability means a child evaluated in accordance with §§ 300.304 through 300.311 as having an intellectual disability, a hearing impairment (including deafness), a speech or language impairment, a visual impairment (including blindness), a serious emotional disturbance (referred to in this part as “emotional disturbance”), an orthopedic impairment, autism, traumatic brain injury, an other health impairment, a specific learning disability, deaf-blindness, or multiple disabilities, and who, by reason thereof, needs special education and related services.

[8] A.P. v Pasadena Unified School District, No 19-7965-MWF (MWJ) (Jan. 26, 2021), [https://www.courtlistener.com/docket/16197861/ap-v-pasadena-unified-school-district/](https://www.courtlistener.com/docket/16197861/ap-v-pasadena-unified-school-district/).

[9] Timothy O. v. Paso Robles Unified School, 822 F 3d 1105 (2016).

[10] (a) General—(1) Child with a disability means a child evaluated in accordance with §§ 300.304 through 300.311 as having an intellectual disability, a hearing impairment (including deafness), a speech or language impairment, a visual impairment (including blindness), a serious emotional disturbance (referred to in this part as “emotional disturbance”), an orthopedic impairment, autism, traumatic brain injury, an other health impairment, a specific learning disability, deaf-blindness, or multiple disabilities, and who, by reason thereof, needs special education and related services.

[11]LJ v. Pittsburgh Unified School Dist, 850 F 3d 996 (2016).

[12] This is defined as “[a] group of people, including the parent/adult student, charged with the responsibility to make decisions regarding evaluation, assessments, and eligibility. This team includes the same membership as the IEP team (although not necessarily the same individuals) and other qualified professionals, as appropriate.” This term should make clear that the evaluation team as a whole needs to have expertise and competent knowledge to be able to make a proper evaluation.

[13] It is unclear even what subsection c refers to with emotional - behavioral disability. It says it is a defined term, but not sure where it is defined.

[14] NB v. Hellgate Elementary School dist. ex rel. Board of Directors, 541 F 3d 1202 (2008).

[15] LJ v. Pittsburgh Unified School Dist, supra note 11.

[16] Roman Martinez et al., Brief for the United States as Amicus Curiae, p. 2, INDEPENDENT SCHOOL DIST. NO. 283 v. EMDH, (2020) 960 F3d 1073 2020 (2020).

[17] Independent School Dist. No. 283 v. EMDH, 960 F 3d 1073 (2020), 960 F 3d 1073 (2020).

[18] Id.

[19] Boothe, supra note 2.

[20] Linda K. Silverman, The Overlooked Role of Modalities in Multi-Exceptional Children, 46 Roeper Rev. 90 (2024), https://doi.org/10.1080/02783193.2024.2309137.

[21] Id.

[22] Id.

[23] Lucas G. Casten et al., The Combination of Autism and Exceptional Cognitive Ability Is Associated with Suicidal Ideation, 197 Neurobiol. Learn. Mem. 107698 (2023), https://www.sciencedirect.com/science/article/pii/S1074742722001228.

[24] Id.

[25] Id.

[26] Lucy Anne Livingston, Punit Shah & Francesca Happé, Compensatory Strategies below the Behavioural Surface in Autism: A Qualitative Study, 6 Lancet Psychiatry 766 (2019).

[27] Courtney Jorgenson et al., Social Camouflaging in Autistic and Neurotypical Adolescents: A Pilot Study of Differences by Sex and Diagnosis, 50 J. Autism Dev. Disord. 4344 (2020).

[28] S. A. Cassidy et al., Is Camouflaging Autistic Traits Associated with Suicidal Thoughts and Behaviours? Expanding the Interpersonal Psychological Theory of Suicide in an Undergraduate Student Sample, 50 J. Autism Dev. Disord. 3638 (2020), http://link.springer.com/10.1007/s10803-019-04323-3 (last visited Apr 30, 2024).

[29] Barbara Jackson Gilman et al., Critical Issues in the Identification of Gifted Students With Co-Existing Disabilities: The Twice-Exceptional, 3 Sage Open 2158244013505855 (2013), https://doi.org/10.1177/2158244013505855 (last visited Jun 3, 2024).

[30] Id.

[31] Jacob J. Michaelson et al., Autism in Gifted Youth Is Associated with Low Processing Speed and High Verbal Ability, medRxiv 2021.11.02.21265802 (2022), http://medrxiv.org/content/early/2022/03/02/2021.11.02.21265802.abstract.

[32] Id.

[33] Amanda Danks et al., Special Education in Ohio.

[34] Id.

[35]Perez v. Sturgis Public Schools, 143 Ct 81 (2022).

[36] Access Idaho, The Legal and Practical Implications of Perez for Youth with Disabilities by Abigael Schulz, State Bar (2024), https://isb.idaho.gov/blog/the-legal-and-practical-implications-of-perez-for-youth-with-disabilities-by-abigael-schulz/ (last visited Jun 3, 2024).

This is (more or less) the comment that I submitted to Idaho Department of Education on June 7, 2024 as it is revising its Special Education Manual. Formatting breaks happen as they only allow comments submitted by “Google Form”. The Idaho Dept of Education had a meeting on July 23-24, to revise, but it is not clear (to me) what the result of meeting is. Please let me know if there are any broken links to the materials, or if you want a resource that is cited.

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Research has established that there is a heightened risk of suicide in the neurodivergent population. Neurodivergent is an umbrella term that describes people with variation in their brain functioning, and can include conditions such as autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), dyslexia, dyscalculia, dyspraxia and tourette’s syndrome. The neurodivergent population is often at risk for a wide range of additional health risks leading to a lower life expectancy, health and mental health issues and overall lower quality of life. These health concerns are often exacerbated by 1) being misunderstood and unaccommodated by our neurotypical society institutions and systems and 2) sensory overwhelm. It is therefore not surprising that recent research has shown that the risk of suicide is significantly higher for autistics and ADHDers overall.

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Many autistics often have additional conditions under the neurodivergence umbrella. In medical terms, their autism is comorbid with additional diagnoses[1]. Often the comorbid condition, ADHD, OCD, major depression,dyslexia, etc, is first diagnosed, and the formal ASD diagnosis arrives much later (or not at all) as it requires special clinical screening that is expensive and often comes with long-wait times of six months to over a year in some cases. Research studies consistently find heightened risk of suicidal behaviours, ideation, attempts and deaths in those with ASD and ADHD, especially if they are un or misdiagnosed. From the research, the risk of suicidality is higher for those with ASD and higher cognitive abilities, and even higher for those with ASD and other comorbid conditions. The risk of suicidality is higher yet again for those that are twice exceptional, defined as high IQ (>120) combined with another disability, such as ASD[2],[3].

To Support, We must Identify

Those with ADHD and ASD that are at the highest risk of failure to identify are those with higher cognitive functioning and compensation skills. It is obviously much easier to identify a non-verbal child. Being autistic comes within a wide spectrum of differing ways of being and often different subsets of mortality risks depending on their way of being. For example, the mortality risk for suicide is even higher for neurodivergents that are LGBTQ+ and/or for those with autism and/or ADHD and higher cognitive abilities. While it was previously thought that higher cognitive ability was protective, research has shown that with autism exactly the opposite is true - higher cognitive ability is significantly related to more suicidal thoughts and deaths in autistics. Higher cognitive functioning in ASD is often defined as greater than 70 IQ. The subset of population of “twice exceptional” children, or children who are “gifted” (higher than 120 IQ) with a “learning disability” (neurodivergent) are at much heightened risk of suicide or significant mental health issues when they are not assessed, identified and supported adequately. It is precisely these neurodivergent boys and especially girls, that are failing to be identified. They are often identified late in life, maybe after their unaccomodated disability spurns a suicidal mental health crises, or tragically not at all. They form a “Lost Generation”.

Suicidality Starts Earlier in Autistics - Schindel Letter

Suicidal, thoughts, & behaviors (“STB”) seem to arrive shockingly earlier in those with ASD (as young as 8)[4]. Reported lifetime STB incidence was as follows: 392 (40.5%) reported wanting to die, 187 (19.3%) reported wanting to end their own life, and 72 (7.4%) reported having a suicide plan. Among those answering affirmatively to each of these questions regarding STBs, onset at 8 years or younger was reported in 142 (36.2%- wanting to die), 66 (35.3%- wanting to end their own life), and 13 (18.1%- a suicidal plan) children, respectively[5].

This study was conducted in those that were clinically diagnosed with ASD and not those who are undiagnosed and/or misdiagnosed[6]. This study is also based on their caregivers’ report, which may understate suicidality, as it requires the caregivers to know what is internalized to the child despite autistics’ known difficulties with communication and (heightened or lessened) sensory perceptions, interoception and alexithymia[7].

The Swedish Study.

This research indicates a higher overall mortality rate in individuals with autism, including from cardiovascular, epilepsy and respiratory illnesses[8]. The overall mortality risks from this study were especially pronounced in those with low-functioning ASD (lower cognitive abilities) and females[9]. Additionally, ASD overall comes with increased risks of death from suicide[10]. The Swedish Study, covered diagnoses from 1987-2009, and shows mortality rates in the ASD population are significantly higher (2-3x) than the general population[11]. The study also found a much heightened risk of suicide in high-functioning ASD at 9.4x the general population[12]. For the unaware, high-functioning ASD more or less encompasses what was previously diagnosed as Aspergers with autism with higher cognitive abilities often measured as >70 IQ. It should be noted that when one hears the word “high functioning” modifying autism, it suggests a life without struggle or without disability; this cannot be further from the truth. The same can be said about the word twice-exceptional, as exceptional is often perceived as “good and outstanding” rather than the intended meaning of rare, not typical. Autism is a difference, but is also a disability when trying to engage with a society that has better communication, emotion recognition, expression, and social interaction skills and does not suffer from sensory sensitivities. In the Swedish Study, suicide was the only specific cause of death showing a higher risk in high-functioning ASD compared with low-functioning ASD[13], and the risk was even higher for females with ASD at 13x the risk of the general population[14].

The Swedish Study was one of the earlier large studies that I could find where a link between higher risk of suicide and suicidal ideation and autism was found. Overall, 83 individuals with ASD in their sample (0.31%) died by suicide, compared with 0.04% of the general population—almost an eight-fold difference[15]. The studies authors identified suicide as one of the top three most common causes of premature mortality among individuals with ASD without co-occurring intellectual disability (ID)[16] what is normally considered high-functioning autism.

The UK Study

This UK Study on suicide and ASD in England indicates a higher prevalence of autism in individuals who died by suicide[17]. The UK Study suggests the need for tailored suicide prevention for autistics and how it is crucial for clinicians to screen for autistic traits and possible undiagnosed autism in patients presenting with suicidal thoughts and behaviours, and to offer appropriate tailored support[18]. The research, based on coroners' inquest records and interviews with next of kin, reveals potential underestimation of suicide rates due to past legal standards of proof regarding cause of death[19]. Key findings include a 10.8% autism prevalence among the deceased when rates of diagnosed autism in the population is generally around 2-3%[20]. This study clearly highlights the importance of considering autism in suicide risk assessments when patterns of suicidal ideation, behaviours and symptoms that are often comorbid with ASD are presented.

This research also demonstrates that both those with clinically diagnosed autism and those that are undiagnosed, but with overlapping autistic traits are significantly more likely to die by suicide[21]. A total of 45% of women with elevated autistic traits...reported making a suicide plan, and 16% had attempted suicide[22]. Only 32% of the sample communicated their suicidal thoughts to another person before they died, and some families reported how the death of their loved one came out of the blue with no obvious warning signs[23].

Additionally the UK Study authors call for a change in environment and the methods and manners in which people with autistic traits are encouraged to seek help[24]. Suicide prevention programs need to consider wider societal issues, such as social exclusion and isolation, poverty, unemployment, trauma and abuse as well as the fact that autistics are often refused assistance as their higher functioning appears to clinicians as “coping” and “functioning”, when it is increasing the risk of suicidal thoughts and other maladaptive behaviours[25].

It should be noted that the UK government has acknowledged the connection between ASD and risk of suicide and added support for studying and developing ASD specific measures to reduce suicide risk in its 5 year plan[26]. In the governmental policy paper on suicide prevention they follow the studies, to say, evidence suggests autistic people, including autistic children and young people, may be at a higher risk of dying by suicide compared with those who are not autistic[27]. They also find it is essential that health, mental health, and local authority services and education providers consider the needs of autistic people in suicide prevention activity[28]. While many actions in this strategy will support autistic people in the UK, all of us in society need to tackle the specific causation factors of suicidality in general, and autism specifically, and tailor support to those that are neurodivergent and struggling versus a one size fits all approach.

Undiagnosed or late-diagnosed autism may be a preventable risk factor for suicide and, therefore, earlier identification and timely access to autism assessment services is vital (emphasis added)[29], [30]. Specific factors that further increase the risk of suicide among autistic people include traumatic, painful life experiences, barriers to accessing support, pressure to ‘camouflage’ or ‘mask’ autism[31] (for example, concealing particular traits that are common in autistic people) and feelings of not belonging[32]. Pressure to conform and to stamp out autistic behaviors that normative viewpoints consider weird or offsetting is contributing to mental health deterioration in autistics and the wider neurodivergent umbrella.

The Utah Kirby study

The Utah Kirby study pulled Utah data over 20 years for those clinically diagnosed with ASD, and demonstrates an elevated risk of death by suicide[33]. Suicide risk in females with ASD diagnosis was over three times higher than in females without ASD[34]. As discussed earlier this study was only for those with a clinical ASD diagnosis (rather than autistic traits), so is limited for those cases where individuals with autism are un or misdiagnosed. The study’s authors also note that suicide determination is given conservatively due to its impact on survivors, which means that there are also suicides that don’t get coded for family, religious, stigma reasons[35]. The authors also mention that it may be particularly difficult in some cases to attribute cause of death with those with ASD as it is more difficult to obtain the “intent” to die[36]. This is similar to the difficulty in knowing intent for whether overdoses are accidental or intentional. Many studies that show a higher 5-10x risk of suicide death, are ones that also include in their studies those with "autistic traits”, or perhaps studies where the participants self-diagnosed/self-report using online tools, rather than solely focusing on clinical diagnoses.

As the Utah Kirby study discusses, the diagnostic criteria for ASD has broadened over time, and ascertainment of accurate ASD diagnosis for those without intellectual disability has improved as well[37]. In other words there is a lost generation of adults that are ASD, but are either never diagnosed or are diagnosed later in their lives[38]. These changes could have affected the observed low incidences in the earlier time periods during which individuals with ASD without ID were likely to be under-ascertained using a community-based, administrative records approach, especially considering the Swedish Study’s[39] finding that suicide in individuals with autism occurred more commonly among those without intellectual disability.

There is evidence that women, especially those with higher cognitive functioning, are often diagnosed with ASD later in life, and some may never receive a formal diagnosis[40]. Therefore, autistic females who died by suicide during the earlier years of this study may have been disproportionately less likely to receive an ASD diagnosis[41]. Females with ASD during the 2013–2017 period, were found to be over five times more likely to die by suicide than their non-ASD peers[42]. The study’s authors noted that the findings related to females with ASD in the most recent time period (2013–2017) are consistent with those of Swedish study[43]. Females with ASD have often been overlooked in research[44] and in unidentified in education and the clinic[45]; the Utah Kirby Study results provide further justification for enhancing focus on females. Some studies have shown that females with ASD may face a variety of challenges including sexual abuse, social difficulties, and conflicts between ASD traits and feminine identity[46]. Traumatic experiences and identity conflicts are known risk factors for suicide in the general population[47]. Further, studies have shown that females may feel the need and have a heightened social ability to “camouflage” or cover-up their autism symptoms[48],[49] with one recent study suggested that these camouflaging behaviors are significantly associated with suicidality in ASD[50]. The Utah Kirby Study also did not differentiate between those with ASD with lower cognitive ability from higher cognitive ability. Studies that have differentiated by cognitive ability in ASD and will be discussed later indicate that the risk of suicide and suicidal ideation is higher for those with higher cognitive functioning and IQ[51],[52].

Meta Studies:

Huntjens Meta Study

This study analyzes the high prevalence of suicidal ideation and attempts in autistic individuals, revealing the need for specialized mental health treatments[53]. This Huntjens analysis estimated the prevalence of suicidal ideation “SI” and suicide attempts “SA” in autistic individuals over a 12-month and a lifetime period across all age groups[54]. Estimates for 12 months (SI: 25.4%, SA: 14.1%) and for lifetime (SI: 37.2%, SA: 15.3%) were consistently higher than the general population’s estimates of (SI: 2.0%, SA 0.3%) over 12 months and (SI: 9%, SA 3%) over a lifetime[55]. The results from this study confirm the substantial magnitude of suicidal thoughts and behaviours in autistics.

Newell - 2023 Meta Study

The Newell 2023 Meta Study reveals a high prevalence of suicidality of both those with a clinical ASD diagnosis and those with autistic traits[56]. Additionally, this study was performed for individuals without intellectual disabilities (above a 70 IQ)[57]. Data from 48,186 participants across 36 studies show pooled prevalence rates of 34.2% for suicidal ideation and 24.3% for suicide attempts, with no significant difference between clinically diagnosed ASD and those individuals with autistic traits[58]. Similar to the Huntjens Meta Study this is significantly higher rates of suicide behaviours than are found in the general population. Cross-national prevalence of suicidal ideation in the general population is approximately 9%, and between 2 and 3% for suicide plans and suicide attempts and behaviours. The risks in the general population are contrasted to those with ASD or autistic traits at 8-12x as high for suicidal attempts and plans[59].

The study’s findings also suggest suicidal ideation is higher in autistic and possibly autistic samples who are transgender or gender non-conforming[60]. This is unsurprising, as transgender and gender non-conforming individuals in the general population exhibit much higher rates of suicidal ideation and suicidal behaviour than their cisgender peers[61]. Along with this, autistic people are more likely to be gender diverse than non-autistic people, and gender-diverse people are also more likely to be autistic[62].

What about those with ASD that have higher functioning cognitive abilities?

For ASD individuals with normal or higher cognitive abilities the risk of premature death by suicide is higher than those that have lower cognitive ability and much higher risk that those without ASD. The risk is even higher in those that are twice-exceptional with both ASD and giftedness, above a 120 IQ.

Carsten Iowa Study

The authors of this study[63] covered the studies that found autism “profoundly increased rates of suicide and depression, in Sweden[64], Japan[65] , Australia[66], meta analysis[67]. The rate of death by suicide has been estimated to be 7.5 times higher in autistic people than those without an autism diagnosis[68]. While rates of suicide death in autistic individuals have varied across samples (0.17 − 0.4% (Kirby[69]; Kõlves[70])) they are consistently higher than rates observed in nonautistic individuals. The increased suicide rate in autism may be partially attributable to a broad increase in depressive symptoms, as autistic people have been shown to have a four-fold increase in lifetime rates of depression[71]. Known protective factors against suicide death, like education, age, and marriage, are not protective in autistic samples (Kõlves[72]). Furthermore, this mental illness burden may be exacerbated by exceptional cognitive ability: in other work, we found that children with an exceptional IQ (≥ 120) and autism have greater feelings of inadequacy and internalizing problems compared to autistic individuals with average IQ[73]. The Carsten Iowa Study findings contrast with research conducted in non-autistic cohorts, where large population studies have found high IQ is a protective factor against suicide death[74], [75], suggesting that the relationship between intelligence and suicide-related traits may vary across diagnostic boundaries”[76]. The Carsten Iowa Study examines the relationship between “exceptional cognitive ability”, autism and suicidality.

Twice-exceptional children (“2E”) are defined as those with both giftedness and a learning disability such as autism, ADHD, dyslexia, etc. The Carsten Iowa study analyzed 2E kids with a diagnosis of autism and high IQ scores >120. For these 2E individuals, they show the highest rate of suicidal thoughts at 12.9%, compared to 2.4% in IQ-matched controls[77]. Additionally, protective factors against suicide death in the general population, like education, age, and marriage, are not protective in autistic samples[78]. Parents of autistic children are found to underreport their child's suicidal ideation[79] and studies would also benefit from a first person perspective[80], [81]. It is often very difficult for parents to know whether their children have suicidal ideation due to difficulties with communication, alexithymia and interoception issues[82], [83]. The results from multiple large samples point toward elevated rates of suicidal thoughts in autism overall, with the highest rates being found in "twice-exceptional" or 2e individuals, i.e., those who were both autistic and had high cognitive ability[84].

The researchers from the Carsten Iowa Study posit that the causes of the increased risk of suicidality in 2E individuals, relate to:

1) In addition to excessive baseline cortisol (think flight or flight adrenal response) linked to autism, it is likely that demonstration of exceptional cognitive ability raises parent, teacher, and peer expectations[85]. Any inability to meet these elevated standards could result in further activation of the hypothalamic-pituitary-adrenal axis, potentially explaining the higher rates of suicidal thoughts we observed in 2e children compared to other autistic children[86].

2) Another mechanism may be found in the relationship between high cognitive ability and "camouflaging"[87], where individuals suppress less socially accepted behavior to fit in. Camouflaging is a universal behavior[88] that has been studied with particular interest in autistic individuals, who engage in this behavior more regularly[89]. In studies of autism, camouflaging has been associated with higher rates of anxiety and depression[90], perhaps due to less support resulting from successful camouflaging, which would tend to delay diagnosis[91]. Consequently, camouflaging in autism is correlated with increased suicidal behavior[92]. Increased cognitive ability may therefore be linked to maladaptive camouflaging that further increases risk for mental health issues in autistic people.[93]

ADHD and Heightened Risk

Individuals with ADHD are also impacted and suffer with higher suicidality[94]. This makes intuitive sense as there appears to be a path toward suicide that is more impulsive in nature[95]. Suicide can appear to an impulsive child to be a permanent solution for a temporary problem. An impulsive ADHDer might attempt suicide on the spur of the moment in response to anger, disappointment, loss, or a whim, where the decision to die by suicide is made within minutes to hours of the attempt[96]. A teen with ADHD may have no intent to die by suicide at the time of his routine follow-up visit where a screening question is asked, but may end his life days or weeks later, on impulse[97].

Undiagnosed ADHD/ASD is linked to a range of negative outcomes, including higher rates of substance abuse, mental health issues, criminal behavior, and lower socioeconomic status[98]. The research demonstrates that identifying ADHD and finding an effective medication improves outcomes and lowers the risk of death, both from suicide and accidental overdose (though it is difficult to impugn intent between accidental and intentional overdoses)[99]. The systemic failure to diagnose ADHD and ASD, leads to a cascade of adverse outcomes that affect not only individuals, but also healthcare, social, and educational systems[100]. There is high overlap between those with both ASD and ADHD, with studies finding 30-50% of those with ASD having ADHD symptoms[101]. Other research is finding even higher rates of up to 75% of those with ASD having ADHD and 15% of the ADHD population having ASD[102].

Combined ADHD and ASD

The combination of autism and ADHD (i.e., dual diagnosis) was made possible in the 2013 DSM-V, prior to which an individual could not be identified as being both ADHDer and autistic[103].

Therefore it is relatively recent that the dual diagnosis of ADHD and ASD was even diagnostically possible. Therefore some studies look to stratify their research into groups of ADHD without ASD traits, and where ADHD individuals also have autistic traits.

As an example is the Blandine French study demonstrates that those children with ADHD+autistic traits experience very severe behavioral, emotional, and educational problems[104]. The combined type of those with ASD and ADHD is often informally referred to as AuDHD and likely comes with its own constellation of heightened risks for lower quality of life, mental illness and earlier mortality[105]. It has been described, being AuDHD is like playing a video game where different people are trying to use the keyboard and the other controls the mouse. Or a more adult description, without censoring for language:

Conclusion:

ASD individuals have a much higher mortality rate from suicide. Those with a high intellectual quotient (IQ) are considered to be at EVEN higher suicidal risk since they tend to not only mask the symptoms of ASD but higher cognitive abilities are also associated with internalizing problems and feelings of inadequacy[106],[107]. The higher IQ and cognitive ability enable more compensation ability for comporting with societal expectations, masking and camouflaging that result in higher suicidality, and internalizing the distress into other conditions, such as anxiety, depression, OCD, etc[108]. Additionally females with ASD in particular are often un and misdiagnosed. These people all need more identification, assessment and support.

Lastly, medical providers, first responders and teachers need specific training on how to support the neurodivergent population. The same interventions that are applied to the neurotypical population cannot be applied to the neurodivergent population, and often cause more harm than good. Neurodivergent people have different brains with different sensory needs. They are prone to more overwhelm. Interventions need to be tailored specifically to support different neurotypes. Neurodivergent individuals need to feel supported in such a way that they are able to “unmask” Autistic individuals need to have their sensory needs supported. Teachers and medical professionals need to learn about autistic burnout[109] and how it is a distinct condition from depression. Many autistic individuals are presenting as suicidal because they are in a state of autistic burnout[110] and our healthcare providers have no idea how to help them. The interventions they are applying are traumatizing them more and making them more suicidal. Schools[111] need to change to be more friendly towards autistic individuals. Early identification[112] is essential for suicide prevention.

ASD, ADHDers and combined AuDHDers may experience difficulty with task initiation, focus, memory, and concentration. Neurodivergents often need more time to process spoken information and respond to questions due to auditory processing speed differences[113]. Allowing ample time for neurodivergents to respond to questions without rushing is critical and necessary to give them time to process the question and answer without scripting an answer as a social avoidance strategy[114]. Additionally, educational and medical practitioners can demonstrate neurodiversity-affirming care by being patient, compassionate, and embracing a non-shaming or judgmental attitude in their interactions and by proactively offering accommodations. The educators, health care providers, and perhaps society at large has a duty to find, effectively treat, accommodate and meet those with sensory, mental health, and processing challenges in the middle. Forcing those that are neurodivergent (a natural state of being), to meet arbitrary societal norms is causing harm. Maybe, to reduce suicidality and mental illness we should all be less hypocrites and more hippocratic.

AFTERWORD

Much of the research cited is open access, though some is not accessible without paid journal credentials. I will try to update this from time to time as new information and research becomes available. I encourage any feedback, edits and suggestions.

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[1] Mikle South, Andreia P. Costa & Carly McMorris, Death by Suicide Among People With Autism: Beyond Zebrafish, 4 JAMA Netw. Open e2034018 (2021), https://doi.org/10.1001/jamanetworkopen.2020.34018 (last visited Apr 29, 2024).

[2] Lucas G. Casten et al., The Combination of Autism and Exceptional Cognitive Ability Is Associated with Suicidal Ideation, 197 Neurobiol. Learn. Mem. 107698 (2023), https://www.sciencedirect.com/science/article/pii/S1074742722001228.

[3] Mark Dlugosz, Twice Exceptional: Definition, Characteristics & Identification, Davidson Institute (2021), https://www.davidsongifted.org/gifted-blog/twice-exceptional-definition-characteristics-identification/ (last visited May 1, 2024).

[4] Schindel, B. J., Chen, B. B., Wilcox, H. C., Marvin, A. R., Law, J. K., & Lipkin, P. H. (2024). Suicidal Thoughts and Behaviors Among Children and Adolescents With Autism Spectrum Disorder. JAMA pediatrics.

[5] Benjamin Joffe Schindel et al., Suicidal Thoughts and Behaviors Among Children and Adolescents With Autism Spectrum Disorder, JAMA Pediatr. (2024), https://doi.org/10.1001/jamapediatrics.2024.0207 (last visited Apr 28, 2024).

[6] Id.

[7] Fionnuala Larkin et al., Alexithymia and Intolerance of Uncertainty Predict Somatic Symptoms in Autistic and Non-Autistic Adults, 27 Autism 602 (2023), https://doi.org/10.1177/13623613221109717 (last visited May 6, 2024).

[8] Tatja Hirvikoski et al., Premature Mortality in Autism Spectrum Disorder, 208 Br. J. Psychiatry 232 (2016), https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/prematuremortality-in-autism-spectrum-disorder/4C9260DB64DFC29AF945D32D1C15E8F2 (last visited Apr 26, 2024).

Id.

[9] Hirvikoski et al., supra note 8.

[10] Id.

[11] Id.

[12] Id.

[13] Id.

[14] Id.

[15] Id.

[16] Id.

[17] Sarah Cassidy et al., Autism and Autistic Traits in Those Who Died by Suicide in England, 221 Br. J. Psychiatry 683 (2022), https://www.cambridge.org/core/product/04367C4DD9D8B4B3375A0D25C4764A54.

[18] Id.

[19] Id.

[20] Id.

[21] Id.

[22] Id.

[23] Id.

[24] Id.

[25] Louise Camm-Crosbie et al., “People like Me Don’t Get Support”: Autistic Adults’ Experiences of Support and Treatment for Mental Health Difficulties, Self-Injury and Suicidality, 23 Autism Int. J. Res. Pract. 1431 (2019).

[26] Suicide prevention in England: 5-year cross-sector strategy, GOV.UK, https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy (last visited Apr 30, 2024).

[27] Cassidy et al., supra note 17.

[28] Suicide prevention in England, supra note 26.

[29] Cassidy et al., supra note 17.

[30] South, Costa, and McMorris, supra note 1.

[31] S. A. Cassidy et al., Is Camouflaging Autistic Traits Associated with Suicidal Thoughts and Behaviours? Expanding the Interpersonal Psychological Theory of Suicide in an Undergraduate Student Sample, 50 J. Autism Dev. Disord. 3638 (2020), http://link.springer.com/10.1007/s10803-019-04323-3 (last visited Apr 30, 2024).

[32] Cassidy et al., supra note 17.

[33] Anne V. Kirby et al., A 20‐year Study of Suicide Death in a Statewide Autism Population, 12 Autism Res. 658 (2019), https://onlinelibrary.wiley.com/doi/10.1002/aur.2076 (last visited Apr 25, 2024).

[34] Anne V Kirby et al., A 20‐year Study of Suicide Death in a Statewide Autism Population, 12 Autism Res. 658 (2019).

[35] Kirby et al., supra note 33.

[36] Id.

[37] Id.

[38] Meng-Chuan Lai & Simon Baron-Cohen, Identifying the Lost Generation of Adults with Autism Spectrum Conditions, 2 Lancet Psychiatry 1013 (2015).

[39] Hirvikoski et al., supra note 8.

[40]Lai and Baron-Cohen, supra note 38.

[41] Kirby et al., supra note 33.

[42] Id.

[43] Hirvikoski et al., supra note 8.

[44] Lai and Baron-Cohen, supra note 38.

[45] Aoife Munroe & Michele Dunleavy, Recognising Autism in Girls within the Education Context: Reflecting on the Internal Presentation and the Diagnostic Criteria, 42 Ir. Educ. Stud. 561 (2023), https://doi.org/10.1080/03323315.2023.2260371.

[46] Sarah Bargiela, Robyn Steward & William Mandy, The Experiences of Late-Diagnosed Women with Autism Spectrum Conditions: An Investigation of the Female Autism Phenotype, 46 J. Autism Dev. Disord. 3281 (2016).

[47] Kirby et al., supra note 33.

[48] Bargiela, Steward, and Mandy, supra note 46.

[49] South, Costa, and McMorris, supra note 1.

[50] Cassidy et al., supra note 31.

[51] Casten et al., supra note 2.

[52] Victoria Newell et al., A Systematic Review and Meta-Analysis of Suicidality in Autistic and Possibly Autistic People without Co-Occurring Intellectual Disability, 14 Mol. Autism 12 (2023), https://doi.org/10.1186/s13229-023-00544-7.

[53] Anne Huntjens et al., The Prevalence of Suicidal Behavior in Autism Spectrum Disorder: A Meta-Analysis., Crisis J. Crisis Interv. Suicide Prev. (2023).

[54] Id.

[55] Id.

[56] Newell et al., supra note 52.

[57] Id.

[58] Id.

[59] Id.

[60] Id.

[61] Id.

[62] Id.

[63] Casten et al., supra note 2.

[64] Hirvikoski et al., supra note 8.

[65] Koji Kato et al., Clinical Features of Suicide Attempts in Adults with Autism Spectrum Disorders, 35 Gen. Hosp. Psychiatry 50 (2013).

[66]Darren Hedley et al., Risk and Protective Factors Underlying Depression and Suicidal Ideation in Autism Spectrum Disorder, 35 Depress. Anxiety 648 (2018).

[67] Chloe C Hudson, Layla Hall & Kate L Harkness, Prevalence of Depressive Disorders in Individuals with Autism Spectrum Disorder: A Meta-Analysis, 47 J. Abnorm. Child Psychol. 165 (2019).

[68] Hirvikoski et al., supra note 8.

[69] Kirby et al., supra note 33.

[70] Kairi Kõlves et al., Assessment of Suicidal Behaviors Among Individuals With Autism Spectrum Disorder in Denmark, 4 JAMA Netw. Open e2033565 (2021), https://doi.org/10.1001/jamanetworkopen.2020.33565 (last visited May 1, 2024).

[71] Hudson, Hall, and Harkness, supra note 67.

[72] Kõlves et al., supra note 70.

[73] Jacob J. Michaelson et al., Autism in Gifted Youth Is Associated with Low Processing Speed and High Verbal Ability, medRxiv 2021.11.02.21265802 (2022), http://medrxiv.org/content/early/2022/03/02/2021.11.02.21265802.abstract.

[74]Ian J. Deary, Alexander Weiss & G. David Batty, Intelligence and Personality as Predictors of Illness and Death: How Researchers in Differential Psychology and Chronic Disease Epidemiology Are Collaborating to Understand and Address Health Inequalities, 11 Psychol. Sci. Public Interest 53 (2010), https://doi.org/10.1177/1529100610387081 (last visited May 7, 2024).

[75] A. Sörberg Wallin et al., Suicide Attempt Predicted by Academic Performance and Childhood IQ: A Cohort Study of 26 000 Children, 137 Acta Psychiatr. Scand. 277 (2018), https://doi.org/10.1111/acps.12817 (last visited May 7, 2024).

[76]Casten et al., supra note 2.

[77] Id.

[78] Id.

[79] L. O’Halloran, P. Coey & C. Wilson, Suicidality in Autistic Youth: A Systematic Review and Meta-Analysis, 93 Clin. Psychol. Rev. 102144 (2022).

[80] Casten et al., supra note 2.

[81] Lucy Anne Livingston, Punit Shah & Francesca Happé, Compensatory Strategies below the Behavioural Surface in Autism: A Qualitative Study, 6 Lancet Psychiatry 766 (2019).

[82] Michael V. Lombardo et al., Self-Referential Cognition and Empathy in Autism, 2 PloS One e883 (2007).

[83] Laura Crane et al., ‘Something Needs to Change’: Mental Health Experiences of Young Autistic Adults in England, 23 Autism 477 (2019), https://doi.org/10.1177/1362361318757048 (last visited May 7, 2024).

[84] Casten et al., supra note 2.

[85] Id.

[86] Id.

[87] Livingston, Shah, and Happé, supra note 81.

[88] Courtney Jorgenson et al., Social Camouflaging in Autistic and Neurotypical Adolescents: A Pilot Study of Differences by Sex and Diagnosis, 50 J. Autism Dev. Disord. 4344 (2020).

[89] Julia Cook et al., Camouflaging in Autism: A Systematic Review, 89 Clin. Psychol. Rev. 102080 (2021), https://www.sciencedirect.com/science/article/pii/S0272735821001239.

[90]Laura Hull et al., Is Social Camouflaging Associated with Anxiety and Depression in Autistic Adults?, 12 Mol. Autism 13 (2021).

[91] Goldie A. McQuaid, Nancy Raitano Lee & Gregory L. Wallace, Camouflaging in Autism Spectrum Disorder: Examining the Roles of Sex, Gender Identity, and Diagnostic Timing, 26 Autism Int. J. Res. Pract. 552 (2022).

[92] Cassidy et al., supra note 31.

[93] Casten et al., supra note 2.

[94] Lin Li et al., ADHD Pharmacotherapy and Mortality in Individuals With ADHD, 331 JAMA 850 (2024), https://doi.org/10.1001/jama.2024.0851 (last visited May 4, 2024).

[95] Fatima Malik et al., Missed Opportunities for Suicide Prevention in Teens with ADHD, 12 J. Affect. Disord. Rep. 100482 (2023), https://linkinghub.elsevier.com/retrieve/pii/S2666915323000215 (last visited May 1, 2024).

[96] Id.

[97] Id.

[98]Blandine French et al., Risks Associated With Undiagnosed ADHD and/or Autism: A Mixed-Method Systematic Review, 27 J. Atten. Disord. 1393 (2023).

[99] Li et al., supra note 94.

[100] Blandine French et al., Risks Associated With Undiagnosed ADHD and/or Autism: A Mixed-Method Systematic Review, 27 J. Atten. Disord. 1393 (2023).

[101] Naomi Ornstein Davis & Scott H. Kollins, Treatment for Co-Occurring Attention Deficit/Hyperactivity Disorder and Autism Spectrum Disorder, 9 Neurother. J. Am. Soc. Exp. Neurother. 518 (2012).

[102] Gagan Joshi & Timothy E. Wilens, Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder in Individuals with Autism Spectrum Disorder, 31 Child Adolesc. Psychiatr. Clin. N. Am. 449 (2022).

[103] Regina Taurines et al., ADHD and Autism: Differential Diagnosis or Overlapping Traits? A Selective Review, 4 Atten. Deficit Hyperact. Disord. 115 (2012).

[104] Amelia Kotte et al., Autistic Traits in Children with and without ADHD, 132 Pediatrics e612 (2013).

[105] Siân Boyle, The Sudden Rise of AuDHD: What Is behind the Rocketing Rates of This Life-Changing Diagnosis?, The Guardian, Apr. 4, 2024, https://www.theguardian.com/lifeandstyle/2024/apr/04/audhd-what-is-behind-rocketing-rates-life-changing-diagnosis (last visited May 8, 2024).

[106] Casten et al., supra note 2.

[107] Mayank Gupta, Nihit Gupta & Theodore Petti, Autism and Suicide: Strategies to Dovetail Emerging Evidence in Child and Adolescent Suicide Risk Assessments, (2023), https://www.researchsquare.com/article/rs-3590767/v1 (last visited May 1, 2024).

[108] Cassidy et al., supra note 31.

[109] 14d85f_824e9f7c7ed24b2c861cb4c497f72c6e.pdf, https://www.autisticadvocate.co.uk/_files/ugd/14d85f_824e9f7c7ed24b2c861cb4c497f72c6e.pdf (last visited May 7, 2024).

[110] Dora M. Raymaker et al., “Having All of Your Internal Resources Exhausted Beyond Measure and Being Left with No Clean-Up Crew”: Defining Autistic Burnout, 2 Autism Adulthood 132 (2020), https://doi.org/10.1089/aut.2019.0079 (last visited May 2, 2024).

[111] Walk In My Shoes, (2020),

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[112] Emily Katy: “Finding out I was autistic saved my life,” https://www.bbc.com/news/uk-england-beds-bucks-herts-68600388 (last visited May 7, 2024).

[113] L Cobbaert & A Rose, Eating Disorders and Neurodivergence: A Stepped Care Approach, Eat. Disord. Neurodiversity Aust. (2023).

[114] Id.