Underrecognized suicidality in higher functioning youth with autism spectrum disorder and attention deficit hyperactivity disorder

Abstract

Abstract Objective To examine factors associated with elevated risk of suicidal thoughts, behaviors, and death by suicide among high functioning individuals with autism spectrum disorder and attention deficit hyperactivity disorder, with particular emphasis on phenotypes characterized by high cognitive ability and delayed recognition. Methods A structured review of the literature was conducted across multiple electronic databases using controlled vocabulary and key terms including suicidal risk, autism spectrum disorder, attention deficit hyperactivity disorder, high functioning, and neurodivergence. After screening for relevance, duplication, and methodological rigor, 7 studies meeting inclusion criteria were synthesized from an initial yield of fifty publications. Results Across studies, individuals with ASD demonstrated a consistently elevated risk of STB and death by suicide compared with the general population, both over the lifetime and within shorter follow up periods. Risk was disproportionately concentrated among individuals without intellectual disability, with higher cognitive ability emerging as a vulnerability factor rather than a protective one. Communication differences, alexithymia, and impaired interoceptive awareness limited the sensitivity of caregiver and clinician assessments, contributing to under recognition of suicidality. Traditional protective factors such as educational attainment, employment, and relationship status did not reliably mitigate risk in ASD and ADHD populations. Camouflaging behaviors and diagnostic overshadowing frequently delayed identification, increasing exposure to cumulative psychosocial stress and untreated mental health conditions. Conclusions High functioning individuals with ASD and co-occurring ADHD represent a concealed yet high risk population for suicidality. These findings underscore the urgent need for autism informed suicide risk assessment, early identification of neurodevelopmental traits in suicidal individuals, and prevention strategies tailored to cognitive profile, developmental history, and comorbidity. Advances in the current screening and intervention frameworks may mitigate adverse outcomes in this vulnerable group.