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.