Why are the Kids Not Alright?
I never thought I would have an article published in a scientific journal. I guess part of life is finding ourselves on dusty roads we never thought we would travel. That said, here are some notes on a new peer-reviewed paper I helped research on the increased suicide risk in “bright”, high-masking autistic and ADHD kids and adults.
I recently co-authored an open-access review that was published in Springer’s journal Discover Mental Health: Underrecognized suicidality in higher functioning youth with autism spectrum disorder and attention deficit hyperactivity disorder. Autism and ADHD are risk factors for increased mental health struggles. That should seem intuitively obvious, but is surprisingly ignored by many sources of information on suicide and autism/ADHD. Few problems get better by ignoring them.
If you only have a minute and don’t actually like to read scientific papers, here is the TLDR on this review of scientific literature:
• The gap from the general population is wide. In a meta-analysis covering more than 88,500 autistic people, roughly 37.2% experience suicidal thoughts in their lifetime and 15.3% report a suicide attempt. In the general population, lifetime estimates sit around 9% for suicidal thoughts and 3% for attempts—roughly 4 to 5 times lower.
• ADHD raises the risk on its own. Across 57 studies, people with ADHD have about 3.5 times the odds of suicidal thoughts, 4.5 times the odds of making a suicide plan, 2.4 times the odds of an attempt, and nearly 6.7 times the odds of dying by suicide compared with peers without ADHD.
• “High functioning” autism does not mean life is easy. In a nationwide Swedish cohort, autistic people overall were 7.5 times more likely to die by suicide than the general population. Break it down by cognitive ability and the pattern flips what most people expect: those without intellectual disability had a 9.4-fold higher risk of dying by suicide (versus 2.4-fold with intellectual disability). Autistic women in that cohort showed a 13-fold higher risk compared with non-autistic women (versus about 6-fold for autistic men compared with non-autistic men) (though newer data suggest actual suicide death rates across autistic men and women may be closer than once assumed; the relative gap is larger for women because non-autistic women start from a lower baseline).
• You don’t need a diagnosis on file to carry the risk. In an English review of 372 coroner inquest records, autism or clinically significant autistic traits appeared in 10.7% of suicide deaths. This is roughly 11 times the estimated population prevalence. Many had no recognized diagnosis at all. Only 32% had told anyone about their suicidal thoughts beforehand, and some families had no obvious warning signs.
• Kids with high cognition and verbal skills often get missed for years. Cognitively able autistic kids are 14.5 times more likely to reach adulthood undiagnosed and 9 times more likely to start school unrecognized than autistic kids with intellectual disability. This is, of course, exacerbated in cases where schools refuse to really look despite their legal obligations under IDEA and Section 504/ADA.
• Autism and ADHD overlap, and may compound some difficulties. Between 30% and 50% of autistic people meet criteria for ADHD (up to 75% in referred clinics). In one sample of mostly college-educated autistic adults, only 17.2% had a formal ADHD diagnosis, yet 45.2% screened positive for likely ADHD. Combine chronic social exhaustion with ADHD impulsivity, and a crisis can move from an acute stressor to an attempt rapidly.
When being “gifted” flips from shield to risk factor
In neurotypical populations, higher intelligence is generally considered as a factor lowering the risks of suicidality. One of the key findings in our review comes from a large University of Iowa study by Lucas Casten, Jacob Michaelson, and colleagues that tested whether the same holds true for autistic kids. It doesn’t.
The Iowa team looked at three large groups: over 1,000 high-achieving youth at a specialized clinic for gifted students, nearly 7,000 autistic kids in the nationwide SPARK cohort, and almost 12,000 non-autistic kids from the general-population ABCD study. The kids at highest risk were the ones who were both autistic and gifted, often called “twice-exceptional.”
At the gifted clinic, twice-exceptional kids (autistic, with an IQ of 120 or higher) had the highest rate of parent-reported suicidal thoughts of any group: 12.9%, compared with 2.4% in non-autistic kids with the same high IQ. That's over five times as often. Being equally gifted didn't make them equally safe.
Larger national samples showed the same pattern once the researchers split kids by IQ. Among non-autistic kids, higher IQ went with fewer parent-reported suicidal thoughts, roughly 2.6% at average IQ down to about 1.4% at exceptional IQ. Among autistic kids, it went the other way, from roughly 12.5% at average IQ up to about 17% for the gifted group. Higher intelligence protected non-autistic kids and raised the risk for autistic kids.
Good grades, a high IQ, a degree, or a steady job don’t seem to protect autistic people in the way generally assumed. When someone is sharp enough to notice every social misstep in high definition, hold themselves to impossible standards, and spend all day camouflaging just to pass as “normal,” cognitive horsepower doesn’t shield them. It can increase mental health risks.
What I wish I had known
I wish someone had told me years ago that ADHD and autism, whether formally diagnosed, or still undiagnosed, are major risk factors for serious mental health crises. My previous concepts of autism and ADHD were forged in the 1980s and 1990s in Twin Falls, Idaho, from Rain Man and ADHD was almost completely ignored.
For a long time, we’ve read the surface backward. When someone is articulate, gets decent grades, keeps a job, and stays polite in the room, everyone assumes they’re fine. If they start cracking under the weight, they usually get handed a standalone label like anxiety or depression, and nobody looks at how their brain is actually wired.
Meanwhile, many autistic and ADHD kids and adults don’t show distress the way checklists expect. Camouflaging hides exhaustion behind competence. Alexithymia (trouble naming what you feel) and differences in interoception (reading your own body’s signals) mean crisis builds quietly out of sight. Quiet gets mistaken for resilient. Ignoring pain signals is encouraged as stoicism.
Should accommodations and support be seen as upstream suicide prevention?
People still debate whether autism and ADHD are medical “disorders” or simply different ways of thinking and processing the world.
We don’t need to settle that debate to see what’s clear in the evidence: children and adults with these different ways of thinking do measurably better, stay safer when they have real social, educational, workplace, and societal supports.
Those supports will look wildly different from one person to the next. For one kid or adult, what helps is sensory breathing room, clear expectations, or extra processing time, being able to follow their own interests. For another, it’s executive-function scaffolding, flexible schedules, peer spaces where they don’t have to translate themselves all day, or mental health care adapted for how they actually communicate. There is no single template.
What shouldn’t be up for debate is the premise. We talk endlessly about “mental health awareness,” yet too often still expect neurodivergent people to do 100% of the adapting inside schools, offices, and clinics built strictly for neurotypical minds. Researchers call that mismatch the double and triple empathy problem and the chronic wear and tear of living inside it is a driver of burnout and despair.
Accommodations and practical supports aren’t special favors or soft extras. They are suicide prevention, and a foundational building block of real mental health awareness and support. Whether someone has a formal diagnosis in hand, is stuck waiting on an evaluation, or has spent years quietly masking to get by, removing unnecessary friction saves lives.
A special thanks
I also want to give a genuine thank-you to my co-authors—Mayank Gupta, Priyal Khurana, and Nihit Gupta—for their leadership, clinical perspective, and tireless work pulling this review across the finish line. None of this paper happens without their care for the research and for the kids and adults behind the numbers.