Increased acceptance of autistic youth and adults into schools, workplaces, and social groups cannot depend only on changing autistic people greater awareness and flexibility is likewise needed for neurotypical partners. This framework is challenged by what autistic scholar Damian Milton 4 has termed the double empathy problem, which recognizes that relational difficulties between autistic and nonautistic partners are a 2-way street: although nonautistic people have the same challenges understanding autistic viewpoints as vice versa, the weight of societal expectations means that autistic people are disproportionately stigmatized and rejected. Understanding the downsides to camouflaging has ramifications for training and support models for autistic people that are often implicitly grounded in a deficit-based framework. This has important implications for many interventions, including social skills training and behavioral therapies that aim to normalize appearance and behavior at the risk of exacerbating a disconnect between the true self and performing self, potentially increasing anxiety and decreasing self-esteem. Quantitative and qualitative research studies show that such camouflaging is exhausting and is associated with poor mental health, including suicidal thoughts and behavior. One helpful question about camouflaging is how much effort the person expends trying to perform as they think others require them to. It is essential to ask autistic people about the underlying motivations for their behaviors, which may be different than clinicians and caregivers assume. Better understanding of autism-associated similarities and differences for symptom course and onset as well as therapeutic response is important for maximizing patient well-being.Īnother important issue is the belief that autistic individuals should camouflage or mask their autistic traits to conform with societal expectations, for example by forcing themselves to make eye contact with others even when doing so is uncomfortable. We note especially the common cooccurrence of autism alongside eating disorders, which may show expected symptoms but different underlying motivations, and with gender diversity, including elevated rates of gender dysphoria. 3 This is a critical failure because a growing body of research shows that many autistic youth and adults benefit from adapted therapies for a range of psychiatric concerns that more effectively integrate their unique strengths and difficulties into treatment. Even when correctly diagnosed, it may be challenging for autistic people to access evidence-based psychological treatments. The reverse likely happens even more frequently: clinicians used to diagnosing mood and anxiety disorders miss additional signs of autism. One is the issue of diagnostic overshadowing, described by Crane et al 2 and others, in which a clinician attuned to autism traits in their patient might overlook or confound signs of depression with autism, thus missing the opportunity to add important therapeutic elements to the treatment plan. These findings both clarify the roadmap for and emphasize the urgency of ongoing research into risk detection and prevention of suicide in autistic people.įindings associated with sex differences and psychiatric conditions coalesce around several important themes. In particular, Kõlves et al 1 found devastating rates of suicide attempts for autistic girls and women (aIRR, 8.51) compared with boys and men (aIRR, 1.93) and for autistic individuals diagnosed with additional psychiatric conditions (aIRR, 9.27), particularly anxiety and affective disorders. Using a Danish population-based sample of more than 6.5 million persons with observations over the course of 10 years, the authors report adjusted incidence rate ratios (aIRRs) more than 3 times higher among individuals with autism for both suicide attempts and deaths, with significantly higher rates compared with the general population across all age ranges, beginning from age 10 years. In this issue of JAMA Network Open, Kõlves et al 1 substantially move this work forward by narrowing the focus from overall mortality to specific data on suicide attempts and deaths and by analyzing targeted risk factors associated with age, sex, and the presence of other cooccurring psychiatric concerns. Several recent population-based mortality studies have demonstrated extraordinarily high rates of death by suicide in autistic youth and adults.
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