Adapted Visual Safety Plan for Autistic Youth (VSP-AY) to Address Self-harm, Suicidal Ideation, and Suicide Behaviors: : A Pilot Randomized Controlled Trial

Background Autistic individuals face a significantly higher risk of suicide compared to the general population, with recent meta-analyses consistently showing rates up to three times higher across various groups, including general autistic samples and those without any intellectual disability. Other meta-analytical data indicate pooled prevalence rates of lifetime suicidal ideation at 37.2% and suicide attempts at 15.3% among autistic individuals.

This increased risk is mainly due to co-occurring psychiatric conditions. Autistic individuals with any psychiatric disorder have 3.55 times higher odds of self-harm compared to those without such conditions. These psychiatric conditions are consistently linked to poorer health outcomes, reduced quality of life, and increased suicidal behaviors.

While suicide among autistic adults has received substantial research attention, autistic youth have been less studied. However, emerging evidence shows that this higher risk also applies to younger groups. Epidemiological research indicates that autistic youth aged 10-19 years have 4.27 times higher rates of suicide deaths and 2.83 times higher rates of suicide attempts compared to their non-autistic peers. A Korean study of school-aged children also found increased rates of parent-reported suicidal ideation among those with autism spectrum disorder compared to neurotypical peers. Similarly, a UK cohort study showed that youth with social communication challenges had significantly higher risks for self-harm with suicidal intent, suicidal thoughts, and suicidal plans by age 16, with depressive symptoms at age 12 partly mediating this relationship.

Clinical studies reveal even more worrying patterns. For example, in an outpatient sample of autistic youth (n=103; aged 10-17 years), 83.5% reported lifetime suicidal ideation and 24.3% had attempted suicide. Despite this high risk, suicide prevention interventions tailored specifically for autistic individuals are still rare. Importantly, no specialized tools are currently available for autistic youth. To fill this gap, the current study protocol describes the development of a new Visual Safety Plan for Autistic Youth (VSP-AY) and details the plan to assess its effectiveness with autistic adolescents.

The Safety Planning Intervention (SPI) is an evidence-based suicide prevention tool that offers personalized coping strategies, organized into six key steps: (1) recognizing warning signs, (2) using internal coping skills, (3) engaging in social interactions for distraction, (4) contacting supportive individuals, (5) reaching out to mental health providers, and (6) removing lethal means. SPI has proven effective in reducing suicidal behavior and increasing treatment engagement among non-autistic adults. Given this demonstrated effectiveness, SPI has become a core recommended element of clinical practice when suicidal thoughts or behaviors are present and can be incorporated into treatment protocols or used as a standalone intervention.