“For me, it is like a tide: it is always there...”: a qualitative exploration of dynamic suicidal thoughts in autistic adolescents

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Abstract

BackgroundAutistic young people are twice as likely to die by suicide than their non-autistic peers, but mechanisms driving this remain undefined. This study explored factors contributing to suicidal thoughts in adolescence (aged 11-15), alongside processes of coping and recovery. MethodsWe conducted reflexive thematic analysis of semi-structured interviews with nine autistic young people (mean age=21.1) to produce conceptual models of: (i) suicide risk; and (ii) recovery. FindingsAn over-arching theme described adolescent suicidal thoughts as omnipresent, fluctuating, and unpredictably building to crisis. Self-exploration uncovered multiple meanings and functions of suicidal thoughts. Nested sub-theme 1 described the development of autistic identity. Early experiences of rejection and de-humanisation resulted in existential questioning; self-discovery, neuroaffirming resources, and neurodivergent communities enabled agency and a protective autistic identity. Nested sub-theme 2 described marginalisation and social identity. Harmful school environments, pressure to mask autistic traits and invalidation in health services resulted in suicidal distress and crisis. Critical consciousness and leaving education enabled autonomy, purposeful coping and pursuit of life goals. Living well as an autistic person offered greatest protection, but recurrent setbacks and others’ lack of understanding hindered progress. InterpretationSuicidal thoughts and feelings were shaped by interactions between autistic young people and their environment and marked by epistemic injustice. Findings resonate with the Integrated Motivational-Volitional model’s emphasis on defeat and entrapment; however, defeat was experienced early, and was pervasive and entrenched, while fluctuations in risk were shaped by harmful environments and neuronormative pressures. Findings further support the COURAGE model of suicide recovery, particularly domains for optimising identity, self-understanding, and meaning in life; however, domains dependent on social acceptance and empowerment were less well-supported, suggesting that opportunities were constrained by broader social and structural barriers. Across both models’ structural factors increased risk and constrained the conditions necessary for autistic people to live meaningful and sustainable lives. Clinicians should prioritise neuroaffirming approaches and resources, but lasting reductions in suicide risk in autistic young people will require structural change, including greater equality of opportunity and an urgent action to reduce the distress of educational environments.

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