California could see an early start to the annual flu season, as a combination of low vaccination rates and late mutations to the virus may leave the state particularly exposed to transmission, health experts say.

Already, there are warning signs. Los Angeles County recently reported its first flu death of the season, and other nations are reporting record-breaking or powerful, earlier-than-expected flu seasons.

Typically, flu picks up right after Christmas and into the New Year, but Dr. Elizabeth Hudson, regional physician chief of infectious diseases at Kaiser Permanente Southern California, said she expects increases in viral activity perhaps over the next two to three weeks.

“We’re expecting an early and likely sharp start to the flu season,” Hudson said.

Last year’s flu season was the worst California had seen in years, and it’s not usual for there to be back-to-back bad flu seasons. But a combination of a decline in flu vaccination rates and a “souped-up mutant” is particularly concerning this year, according to Dr. Peter Chin-Hong, an infectious diseases expert at UC San Francisco.

“That may translate into more people getting infected. And as more people get infected, a proportion of them will go to the hospital,” Chin-Hong said.

The timing of this new flu subvariant — called H3N2 subclade K — is particularly problematic. It emerged toward the end of the summer, long after health officials had already determined how to formulate this fall’s flu vaccine, a decision that had to be made in February.

H3N2 subclade K seems to be starting to dominate in Japan and Britain, Hudson said.

“It looks like a bit of a mismatch between the seasonal flu vaccine strains” and the new subvariant, Hudson said.

It remains unclear whether subclade K will reduce the effectiveness of this year’s flu shot.

In California and the rest of the U.S., “things are quiet, but I think it’s just a calm before the storm,” Chin-Hong said. “From what we see in the U.K. and Japan, a lot more people are getting flu earlier.”

Chin-Hong noted that subclade K is not that much different than the strains this year’s flu vaccines were designed against. And he noted data recently released in Britain that showed this season’s vaccines were still effective against hospitalization.

According to the British government, vaccinated children were 70% to 75% less likely to need hospital care, and adults were 30% to 40% less likely. Flu vaccine effectiveness is typically between 30% to 60%, and tends to be more effective in younger people, the British government said.

Even if there is some degree of mismatch between the vaccine and circulating strains, “the flu vaccine still provides protection against severe illness, including hospitalizations,” according to the Los Angeles County Department of Public Health.

“Public Health strongly encourages everyone who has not received the flu vaccine yet this year to receive it now, especially before gathering with loved ones during the holidays,” the department said in a statement.

But “while mismatched vaccines may still provide protection, enhanced genetic, antigenic and epidemiological … monitoring are warranted to inform risk assessment and response,” according to scientists writing in the Journal of the Assn. of Medical Microbiology and Infectious Diseases Canada.

Because the vaccine is not a perfect match for the latest mutated flu strain, Chin-Hong said getting antiviral medication like Tamiflu to infected patients may be especially important this year, even for those who are vaccinated. That’s especially true for the most vulnerable, which include the very young and very old.

“But that means you need to get diagnosed earlier,” Chin-Hong said. Drugs like Tamiflu work best when started within one to two days after flu symptoms begin, the U.S. Centers for Disease Control and Prevention says.

There are now at-home flu testing kits that are widely available for sale for people who are showing signs of illness.

Also worrying is how the flu has surged in other countries.

Australia’s flu season came earlier this year and was more severe than usual. The Royal Australian College of General Practitioners said that nation saw a record flu season, with more than 410,000 lab-confirmed cases, up from the prior all-time high of 365,000 that were reported last year.

“This is not a record we want to be breaking,” Dr. Michael Wright, president of the physician’s group, said.

Hudson noted Australia’s flu season was “particularly hard on children” this year.

L.A. County health officials cautioned that Australia’s experience isn’t a solid predictor of what happens locally.

“It is difficult to predict what will happen in the United States and Los Angeles, as the severity of the flu season depends on multiple factors including circulating strains, pre-existing immunity, vaccine uptake, and the overall health of the population,” the L.A. County Department of Public Health said.

The new strain has also thrown a wrench in things. As Australia’s flu season was ending, “this new mutation came up, which kind of ignited flu in Japan and the U.K., and other parts of Europe and Asia,” Chin-Hong said.

On Friday, Japan reportedly issued a national alert with flu cases surging and hospitalizations increasing, especially among children and the elderly, accompanied by a sharp rise in school and class closures. The Japanese newspaper Asahi Shimbun said children ages 1 through 9 and adults 80 and up were among the hardest-hit groups.

Taiwanese health officials warned of the possibility of a second peak in flu this year, according to the Central News Agency. There was already a peak in late September and early October — a month earlier than normal — and officials are warning about an uptick in flu cases starting in December and then peaking around the Lunar New Year on Feb. 17.

Taiwanese officials said 95% of patients with severe flu symptoms had not been recently vaccinated.

British health officials this month issued a “flu jab SOS,” as an early wave struck the nation. Flu cases are “already triple what they were this time last year,” Public Health Minister Ashley Dalton said in a statement.

In England, outside of pandemic years, this fall marked the earliest start to the flu season since 2003-04, scientists said in the journal Eurosurveillance.

“We have to brace ourselves for another year of more cases of flu,” Chin-Hong said.

One major concern has been declining flu vaccination rates — a trend seen in both Australia and the United States.

In Australia, only 25.7% of children age 6 months to 5 years were vaccinated against flu in 2025, the lowest rate since 2021. Among seniors age 65 and up, 60.5% were vaccinated, the lowest rate since 2020.

Australian health officials are promoting free flu vaccinations for children that don’t require an injection, but are administered by nasal spray.

“We must boost vaccination rates,” Wright said.

In the U.S., officials recommend the annual flu vaccine for everyone age 6 months and up. Those age 65 and up are eligible for a higher-dose version, and kids and adults between age 2 and age 49 are eligible to get vaccinated via the FluMist nasal spray, rather than a needle injection.

Officials this year began allowing people to order FluMist to be mailed to them at home.

Besides getting vaccinated, other ways to protect yourself against the flu include washing your hands frequently, avoiding sick people and wearing a mask in higher-risk indoor settings, such as while in the airport and on a plane.

Healthy high-risk people, such as older individuals, can be prescribed antiviral drugs like Tamiflu if another household member has the flu, Chin-Hong said.

Doctors are especially concerned about babies, toddlers and young children up to age 5.

“Those are the kids that are the most vulnerable if they get any kind of a respiratory illness. It can really go badly for them, and they can end up extraordinarily ill,” Hudson said.

In the United States, just 49.2% of children had gotten a flu shot as of late April, lower than the 53.4% who had done so at the same point the previous season, according to preliminary national survey results. Both figures are well below the final flu vaccination rate for eligible children during the 2019-20 season, which was 63.7%.

Among adults, 46.7% had gotten their flu shot as of late April, slightly down from the 47.4% at the same point last season, according to the preliminary survey results, which are the most recent data available.

“Before the COVID-19 pandemic, flu vaccination coverage had been slowly increasing; downturns in coverage occurred during and after the pandemic. Flu vaccination levels have not rebounded to pre-pandemic levels,” according to the CDC.

The disparaging of vaccinations by federal health officials, led by the vaccine-skeptic secretary of the U.S. Department of Health and Human Services, Robert F. Kennedy Jr., has not helped improve immunization rates, health experts say. Kennedy told the New York Times on Thursday that he personally directed the CDC to change its website to abandon its position that vaccines do not cause autism.

Mainstream health experts and former CDC officials denounced the change. “Extensive scientific evidence shows vaccines do not cause autism,” wrote Daniel Jernigan, Demetre Daskalakis and Debra Houry, all former top officials at the CDC, in an op-ed to MS NOW.

“CDC has been updated to cause chaos without scientific basis. Do not trust this agency,” Daskalakis, former director of the CDC’s National Center for Immunization and Respiratory Diseases, added on social media. “This is a national embarrassment.”

State health officials from California, Washington, Oregon and Hawaii on Friday called the new claims on the CDC website inaccurate and said there are decades of “high quality evidence that vaccines are not linked to autism.”

“Over 40 high-quality studies involving more than 5.6 million children have found no link between any routine childhood vaccine and autism,” the L.A. County Department of Public Health said Friday. “The increase in autism diagnoses reflects improved screening, broader diagnostic criteria, and greater awareness, not a link to vaccines.”

Hudson said it’s important to get evidence-based information on the flu vaccines.

“Vaccines save lives. The flu vaccine in particular saves lives,” Hudson said.

Dozens of Topanga residents gathered in the town’s Community House to hear Assistant Fire Chief Drew Smith discuss how the Los Angeles County Fire Department plans to keep Topangans alive in a fierce firestorm.

In the red-brick atrium, adorned with exposed wood and a gothic chandelier, Smith explained that if a fire explodes next to the town and flames will reach homes within minutes, orchestrating a multi-hour evacuation through winding mountain roads for Topanga’s more than 8,000 residents will just not be a viable option. In such cases, Smith told attendees at the town’s Oct. 4 ReadyFest wildfire preparedness event, the department now plans to order residents to shelter in their homes.

“Your structure may catch on fire,” Smith said. “You’re going to have religious moments, I guarantee it. But that’s your safest option.”

Wildfire emergency response leaders and experts have described such an approach as concerning and point to Australia as an example: After the nation adopted a similar policy, a series of brush fires in 2009 now known as Black Saturday killed 173 people, many sheltering in their homes.

Some in the bohemian community of nature lovers, creatives and free spirits — who often pride themselves on their rugged, risky lifestyle navigating floods, mudslides, wildfires and the road closures and power outages they entail — are left with the sinking realization that the wildfire risk in Topanga may be too big to bear.

Water tanks called “pumpkins” are available to helicopters to be used during a fire at 69 Bravo, an LAFD Command Center along Saddle Peak Road in Topanga.

They see the shelter-in-place plan as a perilous wager, with no comprehensive plan to help residents harden their homes against fire and no clear, fire-tested guidance on what residents should do if they’re stuck in a burning home.

“Do we need to have some way of communicating with first responders while we are sheltering in place? Would the fire front be approaching us and we’re just on our own?” asked Connie Najah, a Topanga resident who attended ReadyFest and was unsettled by the proposal. “What are the plans for helping people through this season and the next season while we’re waiting to have widespread defensible space implementation?”

No fire chief wants to face the scenario of a vulnerable town with no time to evacuate. But it is a real possibility for Topanga. Smith, speaking to The Times, stressed that the new guidelines only apply to situations where the Fire Department has deemed evacuations infeasible.

“If we have time to evacuate, we will evacuate you,” Smith said.

Emergency operations experts say not enough has been done in their field to address the very grim possibility that evacuating may not always be possible — in part because it’s a hard reality to confront. It’s not a small problem, either: Cal Fire has identified more than 2,400 developments around the state with at least 30 residences that have significant fire risk and only a single evacuation route. Topanga is home to nine of them.

Recent fires, including the 2018 Camp fire in Paradise and Woolsey fire in Malibu, have made the issue too hard to ignore.

In Topanga, Najah has a ham radio license so she can stay informed when power and cell service inevitably go down. The elementary school relocates out of town during red-flag days. A task force including the Topanga Coalition for Emergency Preparedness, the Fire Department and other emergency operations agencies publishes a Disaster Survival Guide and distributes it to every household.

“The survival guide was born out of necessity,” said James Grasso, president of TCEP, who also serves as a call firefighter for the county Fire Department. “We’re pretty isolated. We’re densely populated. Fuel and homes are intermixed. It’s an extremely dangerous area, particularly during Santa Ana wind conditions.”

The guide had instructed residents to flock to predetermined “public safe refuges” in town, such as the baseball field at the Community House or the large parking lot at the state park, to wait out fires. If residents couldn’t make it to these, there were predetermined “public temporary refuge areas” within each neighborhood, such as street intersections and homes with large cleared backyards, that provide some increased chance of survival.

But when the Fire Department determined the spaces were not capable of protecting the town’s entire population from the extreme radiant heat, it pivoted to sheltering in place — the last and most dangerous option listed in the old guide.

Connie Najah, a 16-year resident of Topanga, points out photographs from the Topanga Disaster Survival Guide of places that were once considered “public safe refuges” to be used during a fire.

The survival guide’s old plan was consistent with what emergency response experts and officials have argued across the globe, but it failed to meet typical safety standards for such an approach.

In a March report from the National Institute of Standards and Technology, researchers who spent years investigating the response to the Camp fire recommended a network of safety zones and temporary fire refuge areas as a strategy to keep residents alive.

The report argued that, due to tightly packed combustible structures amid an accumulation of flammable vegetation, “nearly all” communities are “unsuitable” for sheltering in place.

David Shew, a trained architect and firefighter who spent more than 30 years at Cal Fire, said that for a shelter-in-place policy to be viable, a community would need to undertake significant work to harden their homes and create defensible space — work that has not been done in most California communities.

It’s “not really safe for people to just think, ‘OK, I’ve done nothing but they told me to just jump in my house,’” he said.

And once a house ignites, suggestions that Smith offered up at ReadyFest like sheltering in a bathroom are of little use, said Mark Ghilarducci, a former director of the California Governor’s Office of Emergency Services.

“Under certain circumstances, your home could potentially provide a buffer,” he said. But if a house is burning and surrounded by fire in the wildlands, “you’re in a position where you are essentially trapped, and your bathroom’s not going to save you.”

Smith said, however, that the Fire Department had done its own analysis of the Topanga area and determined that the fire dynamics in the area are too extreme for Topanga’s proposed public shelter spaces to be effective.

During hot, aggressive fires like the Woolsey, Franklin and Palisades fires, Smith said, “for 30 to 100 people, you need a minimum of clear land that’s 14 acres, which is 14 football fields.” Many of the safety areas in the survival guide, such as an L.A. County Public Works water tank facility, are barely larger than 1 acre.

The department argues sheltering in place, although far from guaranteeing survival, eliminates the risk of residents getting trapped on roadways, unable to see, with almost no protection.

“There is no way that we can 100% eliminate the fire risk and death potential if you live in a fire-prone area,” Smith said.

Regardless of what residents (or emergency response experts) think of the department’s approach, the safest thing residents can do, experts say, is to always, always, always follow the department’s orders, whether that’s to evacuate, find a safety zone or shelter in their homes. The department’s plan to keep residents alive depends on it.

Still, the history of shelter-in-place policies — and their more aggressive companion, “stay and defend,” which involves attempting to actively combat the blaze at home — looms heavy.

After more than 100 bush fires swept through southeast Australia in 1983, killing 75 people in what became known as Ash Wednesday, Australian fire officials adopted a “stay or go” policy: Either leave well before a fire reaches you, or prepare to stay and fend for yourself. If you’re living in a high fire hazard area, the philosophy goes, it is your responsibility to defend your property and keep yourself alive amid strained fire resources.

Around the same time, California considered the policy for itself after dangerous fires ripped through the Santa Monica Mountains, Ghilarducci said. State officials ultimately decided against it, choosing instead to prioritize early evacuations. Cal Fire’s “Ready, Set, Go!” public awareness campaign became the face of those efforts.

In 2009, an explosive suite of brush fires broke out, yet again, in southeast Australia and seemed to confirm California’s worst nightmare: 173 people lost their lives in the Black Saturday tragedy. Of those, 40% died during or after an attempt to defend their property, and nearly 30% died sheltering in their homes without attempting to defend them. About 20% died while attempting to evacuate.

Afterward, Australia significantly overhauled the policy, placing a much greater emphasis on evacuating early and developing fire shelter building standards.

Nearly a decade later, California confronted its own stress test. The Camp fire ripped through Paradise in the early morning on Nov. 8, 2018. The time between the first sighting of the fire and it reaching the edge of town: one hourand 39 minutes. The time it took to evacuate: seven hours.

Among the miraculous stories of survival in Paradise were the many individuals who found refuge areas in town: a predetermined safety zone in a large, open meadow; the parking lots of stores, churches and schools; a local fire station; roadways and intersections with a little buffer from the burning trees.

But the same day, the intensity of the Woolsey fire in the Santa Monica Mountains — similarly plagued with evacuation challenges — unsettled fire officials. It’s in these conditions that Smith doubted Topanga’s refuge sites could protect residents.

Stuck without many options, the Fire Department began slowly thinking about refining the policies that proved disastrous for Australia. The Palisades fire brought a renewed urgency.

Just a month before ReadyFest, L.A. County Fire Chief Anthony Marrone stirred anxiety among emergency response officials when he appeared to endorse a stay-and-defend policy, telling KCAL-TV, “We’ve always told people that when the evacuation order comes, you must leave. We’ve departed from that narrative. With the proper training, with the proper equipment and with the proper home hardening and defensible space, you can stay behind and prevent your house from burning down.”

The department later clarified the statement, saying the change only applies to individuals in the Santa Monica Mountains’ community brigade who have received significant training from the department and operate under the department’s command. (The brigade is not intended as a means for members to protect their own homes but instead serve the larger community.)

Now, residents worry the policy to shelter in place is coming without enough preparation.

A worker stops traffic that has been reduced to one lane on a portion of Topanga Canyon Boulevard for underground cable installation Nov. 19.

A Times analysis of L.A. County property records found that roughly 98% of residential properties in Topanga were built before the state adopted home-hardening building codes in 2008 to protect homes against wildfires.

However, a significant number of Topangans have opted to complete the requirements regardless. Various fire safety organizations in the Santa Monica Mountains have visited more than 470 of Topanga’s roughly 3,000 residential properties to help residents learn how to harden their homes. These efforts are, in part, why the National Fire Protection Assn. designated the mountain town as a Firewise Community in 2022.

There are some relatively simple steps homeowners can take, such as covering vents with mesh, that can slightly reduce the chance of a home burning. But undertaking a comprehensive renovation — to remove wood decks, install noncombustible siding and roofing, replace windows with multipaned tempered glass, hardscape the land near the house and trim down trees — is expensive.

A report from the community development research nonprofit Headwaters Economics found a complete home retrofit using affordable materials costs between $23,000 and $40,000. With high-end materials that provide the best protection, it can cost upward of $100,000.

Many Topangans have taken up the challenge, anyway. Grasso, who lost his home in the 1993 Old Topanga fire, has slowly been hardening his property since the rebuild. He’s even built a concrete fire shelter against a hillside with two steel escape doors and porthole windows.

Researchers have found comprehensive home hardening and defensible space can reduce the risk of a home burning by about a third, but not bring it down to zero. (Albeit, none have tested Grasso’s elaborate setup.)

Wildfire safety experts hope the state someday adopts building standards for truly fire-proof structures that could withstand even the most extreme conditions and come equipped with life-support systems. But any such standards are years away, and the L.A. County Fire Department has to have a plan if a fire breaks out tomorrow.

For Grasso, fire risk is a risk like any other, like the choice to drive a car every day. In exchange for the beauty of living life in Topanga, some folks will learn to accept the risk and do what they can to mitigate it: Harden a home, fasten a seat belt. Others — especially those unable to take the drastic steps Grasso has been able to — will deem the beauty of life in Topanga not worth the risk of getting trapped by flames.

“The amount of money it takes to get to this point is too cost-prohibitive for us at this moment,” Najah said. “It’s really a tough place to be in. … It’s not going to be easy, and we’re not the only rural community. All over the state, people are having to deal with this.”

Times assistant data and graphics editor Sean Greene contributed to this report.

When Anthony Tricarico was diagnosed at 7 with autism spectrum disorder, his parents, Neal and Samara, were told that he might need extra support at school, so they made sure he got it. When doctors suggested therapies for his speech and motor skills, they sought those out too.

But when their kind, popular, accomplished boy began to experience depression and suicidal ideation as a teenager, no one told them that the same thinking patterns that powered many of Anthony’s achievements might also be amplifying his most harmful thoughts, or that the effort of masking his autism could be hurting his mental health.

None of the people or organizations they contacted for help said Anthony might benefit from therapies or safety plans adapted for autistic people, or even that such things existed. They did not say that he might not show the same warning signs as a non-autistic teenager.

And only after he died from suicide in May 2024 did the San Diego County couple discover that autistic kids — particularly those like Anthony, whose disability is not immediately apparent from the outside — are more likely to think about and die from suicide, and at earlier ages, than their neurotypical peers.

“Our son has always been different. So why wouldn’t how we approach suicide be different?” Neal said.

Suicide is a leading cause of death in the U.S. for kids aged 10 to 18. Prevention strategies that take neurodiversity into account could go a long way toward reducing the number of young lives lost too soon.

Autism researchers and advocates are working to develop better screening tools and interventions based on the unique strengths and differences of an autistic brain. A crucial first step is educating the people best positioned to help kids when they’re in crisis, like parents, counselors, pediatricians and social workers.

“These are kids that are experiencing all sorts of heightened risk,” said Danielle Roubinov, an associate professor and director of the Child and Adolescent Anxiety and Mood Disorders Program at University of North Carolina at Chapel Hill. “We’re aware of the need for tailored approaches. We’re doing this research. We’re trying to get the word out. And [suicidality] is something that is treatable. This is something that responds to intervention.”

The percentage of U.S. children with an autism diagnosis has risen steadily in recent decades, from 1 in 150 8-year-olds in 2000 to 1 in 31 in 2022.

The diagnostic definition has changed dramatically in that time, inscribing children with a broad range of abilities, needs and behaviors within a single term: autism spectrum disorder.

Today, the diagnosis includes children whose autism was previously overlooked because of their propensity for “masking,” the act of consciously or unconsciously suppressing autistic traits in order to blend in.

Samara and Neal Tricarico with a portrait of Anthony at their home.

For autistic children without intellectual disabilities, like Anthony Tricarico, masking often enables them to participate in mainstream classes or activities. It’s also why many children, especially girls, aren’t diagnosed with autism until later in childhood.

Masking can exact a powerful psychological toll on autistic kids, and is strongly correlated with depression, anxiety and suicide.

Anthony Tricarico was bright, athletic and autistic. His parents, Neal and Samara Tricarico, share what they wish they’d known when their son first started to struggle with his mental health.

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Children across the autism spectrum are far more likely to struggle with mental health conditions than their allistic, or non-autistic, peers. A 2021 study of more than 42,000 caregivers of children ages 3 to 17 found that 78% of autistic children had at least one co-occurring psychiatric condition, compared with 14% of non-autistic kids. Contributing factors include the stress of living in a world that’s sensorially overwhelming or socially impenetrable. Lights, noises, smells and crowds that others barely notice may cause incapacitating anxiety.

For kids who cope by masking, constantly deciphering and mimicking social responses is often cognitively and emotionally exhausting. “Masking is actually a risk factor of suicide for autistic people,” said Lisa Morgan, founder of the Autism and Suicide Prevention Workgroup, who is autistic herself.

One of many rocks in honor of Anthony that have been left in the family’s memorial garden.

Autistic people at all ages are more likely to die by suicide than those who aren’t autistic. That disparity begins early. One 2024 meta-analysis found that some 10% of autistic children and teens had attempted suicide, a rate more than twice that of non-autistic peers.

Their struggles are often invisible.

Neal and Samara had never heard of masking.

They saw how Anthony thrived on schedules and sameness. He rose precisely at 5 a.m. for a long workout, chugged the same protein shake afterward, took a shower at 7 a.m. on the dot. At the time they thought he was extremely disciplined; they believe now it was also Anthony’s way of fulfilling his need for routine and predictability, a common autistic trait.

They also saw that he preferred to keep his diagnosis a secret.

Anthony’s black belt in karate rests on a table in the family home.

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In middle school, Anthony announced that he no longer wanted any accommodations for his autism: no more individualized education program, no more behavioral therapy, no more telling new friends or teachers about his diagnosis.

“It’s my belief he just wanted all that to go away, and to just be like everyone else,” Neal said.

The pandemic hit Anthony hard. He couldn’t work out at his favorite spots or fish, a beloved pastime. Other kids might have defied the closures and gone anyway, but Anthony followed rules with inflexible intensity, Neal said, especially the ones he set for himself.

His mental health started to decline. In 2022, during his freshman year, Neal and Samara learned that Anthony told a friend he was having thoughts of suicide.

They called the California suicide hotline, where a volunteer told them to contact his school. A counselor determined that since Anthony didn’t have a plan, he wasn’t at immediate risk.

When Neal and Samara asked him about it, he sounded almost dismissive. It was fleeting, he said. It wasn’t real.

Neal looks over a living room table covered in photographs and medals Anthony won in 5Ks, half marathons and other athletic competitions.

It’s impossible to know Anthony’s true thoughts. What is known is that suicidal ideation can look very different in autistic kids.

About a decade ago, psychiatrist Dr. Mayank Gupta started noticing an uptick in a particular type of patient at the western Pennsylvania inpatient facilities in which he worked: bright children from stable home environments who began having serious suicidal thoughts in early adolescence.

They showed few of the typical youth-suicide risk factors, like substance use or histories of neglect. A surprising number had autism diagnoses.

At the time, Gupta associated autism with behaviors like minimal verbal communication and noticeable differences in body language or eye contact. Nothing in his training or continuing education discussed the breadth of the autism spectrum, or how it might relate to children’s mental health.

He searched the literature, and was stunned to find how much published work there was on autism and suicide.

“In the last seven to eight years, there’s been more and more evidence, and more and more research,” he said. But not enough of it has made its way to the local psychologists, psychiatrists and pediatricians that parents are most likely to turn to for help with a struggling child.

Adults often assume that a child who can speak fluently on a variety of subjects can explain their thoughts and feelings with a similar level of insight. But up to 80% of autistic kids have alexithymia, or difficulty identifying and describing one’s own internal emotional state. For this reason, “it makes sense that all of the interventions that have been designed for a neurotypical youth probably aren’t going to translate in the same way to autistic youth,” said Jessica Schwartzman, director of the Training and Research to Empower NeuroDiversity Lab at Children’s Hospital Los Angeles and assistant professor of pediatrics at USC’s Keck School of Medicine.

Autistic people are often stereotyped as unable to read other people, Morgan said, but neurotypical people often have just as hard a time accurately interpreting an autistic person’s emotional state.

“What people are looking for is that really outward display of emotions and tears and angst,” said Morgan, of the Autism and Suicide Prevention Workgroup. “But for autistic people, that all can be happening on the inside without the autistic person being able to communicate that. And in fact, the further in crisis they go, the less they’re able to verbally communicate.”

As high school progressed, Anthony gave “the appearance of thriving,” Neal said: a 4.6 grade-point average, two part-time jobs, a busy social life. He ran marathons and finished grueling Spartan Races.

“But for us, living with him every day, we saw the black-and-white thinking really, really intensify,” Neal said. “The intensity and speed with which he was coming up with new things to achieve became more and more, and the feeling of lack of fulfillment became even greater.”

In 2023, Anthony told his mother that the suicidal thoughts were back. He wanted to go to an inpatient facility that could keep him safe.

They dialed every number they could find. They called a county mobile crisis response team, which determined that since Anthony had no clear plan, he likely wasn’t at risk. They called a therapist he’d seen when he was younger. But Anthony was clear: He wasn’t OK and needed to be somewhere that could help.

When they finally found a facility able to admit him, they checked him in with a sense of relief. Immediately, they all felt they’d made a mistake.

Some of the medals Anthony won in marathons, Spartan Races and other competitions.

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The only available bed was in solitary confinement. He couldn’t exercise, go outside or follow his routines.

Emergency rooms or inpatient facilities are sometimes the only option to keep someone safe during a suicidal crisis. But separated from familiar settings, objects and routines, and inundated with stimuli like bright lights, many autistic kids find them more disturbing than therapeutic, researchers said.

“The people that work in those facilities are obviously incredible, but they may or may not have special training in strategies and communication practices and approaches that are tailored to meet the needs of autistic individuals,” Roubinov said.

Anthony called his parents begging to come home. After two nights, the Tricaricos signed him out. On the way home Samara asked him to promise he’d tell them if he ever had suicidal thoughts again.

“He said, ‘No. I will never,’” she recalled.

His parents interpreted his words to mean he’d never think that way again, and that the worst was over. They now believe he was really saying that he had lost hope.

Another year passed. In March 2024, Anthony and his sister met up with friends who later said he seemed happier than he’d been in a while. He gave one an envelope of cash he’d saved and told her to take herself to Disneyland.

He was surrounded by people who cared about him, all unaware that he was displaying classic warning signs of an imminent crisis: giving away valuables, a sudden lift in spirits, indirectly saying goodbye.

The next day he was quiet and downcast.

“I could tell he had been crying, and I said, ’What’s going on? Is it friends? Is it work? Is it school work?’” Samara recalled. “And he said, ‘It’s all of it.’”

That afternoon, after finishing his chores, Anthony told his parents he was going for some fresh air, which he often did to clear his head. They could see on their phones that he was taking a familiar route through their Cardiff-by-the-Sea neighborhood.

His icon paused. Maybe he got a phone call, his parents thought, or bumped into friends.

Dusk fell. Samara’s phone rang with a call from Anthony’s number. It was a sheriff’s deputy. They’d found him.

Anthony spent nine weeks in the hospital. He died on May 25, 2024. He was 16 years old.

Colorful, painted rocks in honor of Anthony decorate a memorial garden.

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Months later, Neal got a message from a Facebook friend who worked at a suicide-prevention foundation, asking if he knew about the particular risks facing autistic kids.

It was the first time he’d heard of anything of the sort.

They scheduled a Zoom call and she walked him through all of it: The stats, the research, the reasons that warning signs for kids like Anthony can look so different that the most attentive parents can miss them.

There is no simple explanation for why any one individual dies by suicide. As seriously as Neal and Samara took their son’s mental health struggles, it was impossible to imagine him ending his life. It didn’t fit with his zeal for living or his disdain for shortcuts. In retrospect, they say, it was also too frightening to contemplate.

But had they known how common such thoughts and actions are for young people in Anthony’s sector of the autism spectrum, they said, they would have approached it differently.

“You drive yourself crazy saying, ‘what if,’ Samara said. “But I would have liked to have known that, because it potentially could have saved his life.”

About 20% of U.S. high schoolers disclosed suicidal thoughts in 2023, according to the Centers for Disease Control and Prevention. When the Kennedy Krieger Institute in Baltimore asked caregivers of 900 autistic children if the children had thought about ending their lives, 35% said yes. Nearly 1 in 5 had made a plan. The youngest respondent was 8 years old.

The risk may be particularly high for gifted kids trying to function in a world designed for a different way of thinking. In one 2023 study from the University of Iowa, autistic kids with an IQ of 120 or higher were nearly six times more likely to have suicidal thoughts than autistic children with average IQ. For non-autistic children, the opposite was true: Higher cognitive ability was associated with a decreased risk of suicide.

There’s no clear protocol for families like the Tricaricos. There are therapists and psychiatrists specially trained in autism, but not enough to meet demand.

Researchers are, however, looking for ways to tailor existing therapies to better serve autistic kids, and to educate healthcare providers on the need to use them.

One starting point is the Columbia-Suicide Severity Rating Scale, the standard that healthcare professionals currently use to identify at-risk children in the general population. Schwartzman’s lab found that when the questionnaire was administered verbally to autistic kids, it flagged only 80% of those in the study group who were having suicidal thoughts. A second, written questionnaire identified the other 20%. Schwartzman recommends that providers use a combined spoken and written screening approach at intake, since some autistic people find text questions easier to process than verbal ones.

Another candidate for adaptation is the Stanley-Brown safety plan, a reference document where patients list coping strategies, helpful distractions and trusted contacts on a one-page sheet that can be easily accessed in a crisis. Research has found that people with a completed plan are less likely to act on suicidal thoughts and more likely to stick with follow-up care. It’s cheap and accessible — free templates in multiple languages can be easily found online.

But like most mental health treatments, it was developed with the assumption that the person using it is neurotypical. There isn’t much research on whether the Stanley-Brown is less effective for autistic people, but researchers and advocates say it stands to reason that some tailored adjustments to the standard template could be helpful.

Shari Jager-Hyman, a clinical psychologist and assistant professor at the University of Pennsylvania’s Perelman School of Medicine, and Lisa Morgan of the Autism and Suicide Prevention Workgroup are creating an autism-friendly version.

Some changes are as simple as removing numbered lines and leaving blank space under headings like “Sources of support.” Many autistic people think literally and may perceive three numbered lines as an order to provide exactly three items, Morgan said, which can be especially disheartening if there aren’t three people in their circle of trust.

Jager-Hyman and Roubinov, of UNC, are currently leading a study looking at outcomes for suicidal autistic children who use the modified Stanley-Brown plan.

The way adults interact with autistic children in crisis may also make a difference. Sensory overload can be extremely destabilizing, so an autistic child may first need a quiet place with dim lighting to calm themselves, and extra time to process and form answers to providers’ questions.

For parents and other caregivers, the best thing they can offer might be a quiet, supportive presence, Morgan said: “For an autistic person, it could be they want somebody there with them, but they just want to sit in silence.”

The knowledge Neal and Samara have acquired since losing Anthony has felt to them like a missing piece that makes sense of his story, and a light illuminating their path ahead.

Earlier this year, they founded the Endurant Movement, a nonprofit dedicated to autism, youth suicide and mental health. They have joined advocates who say the most effective way to reduce rates of depression, anxiety and the burden of masking is to ensure that autistic kids have the support they need, and don’t feel like they have to change everything about themselves in order to fit in.

“Suicide prevention for autistic people is being accepted for who they are, being able to be who they are without masking,” Morgan said.

The Tricaricos imagine interventions that could make a difference: practical, evidence-based guidelines that families and clinicians can follow when an autistic child is in crisis; information shared at the time of diagnosis about the possibility of co-occurring mental health conditions; support for autistic kids that frames their differences as unique features, not deficits to be overcome.

And above all, a willingness to have the hardest conversations before it is too late.

There is a common misconception that asking about suicide could plant the idea in a child’s head and lead to further harm. If anything, researchers said, it’s protective. Ask in whatever way a child is comfortable with: a text, a written letter, in conversation with a trusted therapist.

“Suicide is so stigmatized and people are so afraid to talk about it,” Samara said. “If we can talk about it, invite the conversation, we can normalize it so they can feel less alone.”

She and Neal were seated next to each other on a bench in their front garden, surrounded by rocks friends and family had painted with tributes to Anthony.

“We didn’t know that our son was going to take his life this way. If we knew that having the conversation could help, we would have,” she said, as Neal nodded.

“And so that’s the message. Have the conversation, as difficult as it feels, as scary as it is … . Have the courage to step into that, knowing that that could possibly save someone’s life. Your child’s life.”

If you or someone you know is struggling with suicidal thoughts, seek help from a professional or call 988. The nationwide three-digit mental health crisis hotline will connect callers with trained mental health counselors. Or text “HOME” to 741741 in the U.S. and Canada to reach the Crisis Text Line.

This article was reported with the support of the USC Annenberg Center for Health Journalism’s National Fellowship’s Kristy Hammam Fund for Health Journalism.