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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Self-harm and suicide-risk assessment

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Imminent suicide or untreated injury

Current intent with an actionable plan or access to means, severe agitation or psychosis, inability to maintain safety, significant overdose, bleeding, altered consciousness or dangerous injury requires immediate supervised emergency care.

Action: Use ABCDE and the appropriate toxicology or injury pathway, maintain compassionate observation in a safe environment, remove accessible means proportionately, obtain urgent paediatric and mental-health assessment, involve carers and safeguarding services when necessary, and do not leave the young person alone during transfer.

Overview

Respond compassionately to self-harm or suicidal thoughts, treat physical injury or poisoning first, develop an individual formulation rather than a score-based prediction, identify immediate and contextual danger, create a collaborative safety plan, and secure psychosocial assessment and reliable follow-up.

Start with calm validation: thank the young person for explaining, treat pain and ask what they need now. Avoid demanding a promise never to self-harm or framing the episode as attention seeking. Establish what happened before, during and after the act; the method, dose, timing, expected lethality, precautions against discovery, help-seeking and feelings about survival. Ask separately about the function of self-injury and desire to die because both can coexist and change rapidly. Obtain collateral information with consent where possible, but immediate protection can justify proportionate sharing.

The mental-state assessment includes mood, hopelessness, anxiety, agitation, psychosis, mania, dissociation, intoxication, cognition and ability to engage. Explore sleep, pain, eating disorder, substances, neurodevelopment, medication changes, loss, conflict, abuse, exploitation, bullying, discrimination and online exposure. Identify protective relationships, future commitments, beliefs, pets, responsibilities, coping and previous successful help. Protective factors reduce neither the need to ask about current intent nor the significance of access to a lethal method; they become practical elements of the safety plan.

Practice

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Paediatrics and child healthOriginal SBA

Risk tools and discharge

A medically stable 16-year-old is assessed after self-harm. A screening tool gives a low score, but the young person has rehearsed a suicide plan and can access the means. What should guide disposition?

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Sources and review status3 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE Self-harm NG225Current assessment, psychosocial care, safety planning, risk-tool restrictions, aftercare and service recommendations for self-harm.
  • NICE Depression in children NG134Recognition and stepped treatment of depression in children and young people, including assessment of self-harm and suicide.
  • NHS Urgent mental health helpCurrent public routes to urgent NHS mental-health support and emergency services in crisis.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

NICE advises against using risk-assessment scales or global low, medium or high stratification to predict future suicide or decide who receives treatment or discharge. Formulation instead explains the current crisis, enduring vulnerabilities, recent triggers, maintaining factors, available means, strengths and plausible changes that would worsen or improve safety. State concrete concerns and actions: for example, current intent plus accessible medication and intoxication requires supervised urgent assessment, whereas no current intent still needs psychosocial assessment, means safety and reliable follow-up after an episode.

A safety plan is collaboratively written in the young person's language and accessible format. List warning signs, coping activities that need no contact, safe distractions and people, trusted adults, clinical crisis routes and emergency services. Agree proportionate removal or secure storage of the method involved and other likely means, including quantities of medicines, firearms where relevant, heights, ligatures or online purchasing. Means restriction should be specific and reviewed; telling a family simply to 'keep an eye on them' is insufficient and may be impossible or unsafe.

Discharge is a clinical transition, not the end of risk. Complete medical and psychosocial assessment, communicate the formulation and safety plan, reconcile medicines, give wound care and arrange a definite follow-up with the receiving service. Confirm transport and supervision and check that the home is safe. If a young person wants to leave before assessment, review immediate medical risk, competence or capacity, mental-health and safeguarding powers and obtain senior advice. Active follow-up is particularly important after hospital or crisis-service discharge and after missed contacts.

Key points

  • Treat injury, overdose and altered physiology first while beginning a compassionate mental-state and safeguarding assessment; psychological need never makes physical symptoms less real.
  • Ask directly about thoughts of death, current intent, plan, preparation, access to means, deterrents, expected rescue and what has changed today; direct questions do not create suicidal ideas.
  • Do not use a risk scale or low, medium or high label to predict suicide or decide discharge; build an individual formulation of needs, risks, strengths and near-term triggers.
  • Explore the function and sequence of self-harm, previous episodes, medical lethality, impulsivity, substances, sleep, psychosis, mood, eating, neurodevelopment and recent service transitions.
  • Speak privately but involve parents or a trusted adult when safe and necessary, explaining confidentiality limits and checking whether the home response could involve violence, rejection or coercion.
  • Create a written safety plan with personal warning signs, internal coping actions, supportive people and places, professional crisis contacts, restriction of relevant means and reasons for staying alive.
  • Arrange psychosocial assessment by an appropriately skilled mental-health professional after every self-harm presentation and make transfer and follow-up active rather than handing over a telephone number alone.
  • Provide respectful wound and scar care, medicine-supply review, sleep and substance support and a rapid route back if suicidal intensity, injury or home safety worsens.

Aetiology

01

Acute distress and entrapment

Conflict, loss, humiliation, bullying, trauma or perceived burdensomeness can narrow problem solving and make self-harm feel like escape, communication or emotional regulation.

02

Mental and neurodevelopmental illness

Depression, anxiety, psychosis, bipolar disorder, eating disorder, substance use, autism and ADHD may increase vulnerability but never determine individual intent alone.

03

Social and environmental exposure

Abuse, deprivation, unstable care, discrimination, access to means and online material can amplify risk, while safe relationships and timely support can reduce it.

Pathophysiology

  1. 1
    Stress-system activation

    Intense affect, sleep loss and threat arousal impair flexible problem solving and increase impulsive action during a short-lived crisis.

  2. 2
    Negative reinforcement

    If self-injury briefly reduces unbearable emotion or dissociation, that immediate relief can reinforce repetition despite later shame, injury and family conflict.

  3. 3
    Capability and access

    Repeated exposure to pain, rehearsal and ready access to a chosen method can lower practical barriers between suicidal thinking and a lethal act.

  4. 4
    Protective interruption

    Connection, restricted access to means, coping steps and rapid clinical contact create time and alternatives while suicidal intensity fluctuates.

Clinical features and red flags

Current suicidal crisis

Intent, a feasible plan, preparation, access to means, hopelessness and inability to identify any interruption indicate need for immediate supervised assessment.

Self-injury for regulation

Cutting, hitting, burning or other injury may temporarily reduce distress or dissociation without a settled wish to die, yet still carries future risk.

Hidden medical danger

An uncertain dose, delayed-toxicity medicine, wound depth, neurovascular symptom or altered observation requires continued physical assessment despite a calm appearance.

Unsafe environment

Violence, rejection, exploitation, bullying, unsecured means, substance access or an unable carer can make discharge unsafe even if acute intent falls.

Potential protective leverage

A trusted person, meaningful activity, willingness to accept help, future event or previously effective strategy can be converted into a specific safety-plan action.

Red flags requiring action

  • A current plan, preparatory behaviour, rehearsal, access to lethal means, suicide note or belief that death is inevitable indicates high immediate concern regardless of a screening score.
  • Escalating frequency or lethality, multiple methods, regret at survival, concealed rescue prevention or a recent discharge or bereavement increases concern.
  • Severe intoxication, psychosis, mania, agitation, dissociation, cognitive impairment or overwhelming shame may make stated reassurance unreliable until the acute state resolves.
  • Abuse, exploitation, bullying, family violence, homelessness, criminal involvement, online contagion or an unsafe adult response requires parallel safeguarding action.
  • Unexpected drowsiness, vomiting, abdominal pain, arrhythmia, bleeding or inconsistent overdose history requires ongoing medical assessment because toxicity can be delayed.

Investigations

  1. 01
    ABCDE and exposure-specific examinationFirst step
    Why
    Detect and treat injury, poisoning and physiological compromise before deterioration.
    Interpretation and limitations
    Normal appearance does not exclude delayed toxicity; use the stated and possible method, timing, symptoms and observations to select monitoring and toxicology advice.
  2. 02
    Individual psychosocial formulation
    Why
    Explain near-term danger, needs, maintaining factors and available protection.
    Interpretation and limitations
    Integrate intent, plan, preparation, means, episode function, mental state, history, triggers, environment, strengths and engagement; do not convert this into a predictive category.
  3. 03
    Mental-state examination
    Why
    Identify treatable syndromes and factors impairing reliable safety decisions.
    Interpretation and limitations
    Agitation, psychosis, intoxication, severe depression, mania, dissociation or cognitive change influences supervision and treatment but no diagnosis alone predicts an individual act.
  4. 04
    Safeguarding and environment review
    Why
    Determine whether home, carers, peers or online contacts increase immediate harm.
    Interpretation and limitations
    Ask privately about abuse, exploitation, rejection, bullying, coercion, means access and safe adults, then share proportionately when protection is necessary.
  5. 05
    Method-directed tests
    Why
    Assess specific overdose or injury consequences under an evidence-based pathway.
    Interpretation and limitations
    Use ECG, glucose, paracetamol concentration, renal or liver tests, imaging or wound assessment only as indicated by timing and possible exposure, with poisons-service advice.

Differential diagnosis

01

Non-suicidal self-injury

Injury may aim to regulate emotion without intent to die, but intent can vary between episodes and future suicide risk still requires assessment.

02

Accidental injury or poisoning

Recreational use, medication error and accidental trauma may resemble deliberate harm; clarify context without allowing uncertainty to delay medical treatment.

03

Abuse or inflicted injury

Another person may cause, coerce or exploit injury, and a young person may conceal this through fear, loyalty or threats.

04

Stereotyped or compulsive behaviour

Neurodevelopmental stereotypy, skin picking, tics and obsessive-compulsive phenomena need a different formulation while still prompting injury and distress assessment.

Management

01ImmediateTreat and superviseFirst stepThere is injury, poisoning, altered physiology, current intent, accessible means or inability to remain safe.+
  1. 1Use ABCDE, control bleeding, treat pain and follow method-specific toxicology or surgical guidance without waiting for psychiatric clearance.
  2. 2Provide compassionate observation in an appropriate safe area and remove immediate means without humiliating searches or isolation.
  3. 3Obtain urgent paediatric and mental-health review, involve a safe carer and activate safeguarding or police support only as proportionate.
  4. 4Use senior legal and mental-health advice if the young person attempts to leave or refuses essential life-saving assessment.
02AssessFormulate the crisisThe young person is medically able to participate in psychosocial assessment.+
  1. 1Reconstruct events, intent, function, preparation, expected rescue, access to means, prior episodes and feelings about survival.
  2. 2Assess mood, psychosis, substances, sleep, neurodevelopment, trauma, relationships, online exposure, safeguarding, strengths and practical supports.
  3. 3Describe dynamic concerns and needs rather than assigning a low, medium or high predictive label.
  4. 4EscalationAgree which changes would require escalation and what interventions can alter each modifiable driver.
03TransitionPlan safety and follow-upA disposition decision is being made after medical and psychosocial assessment.+
  1. 1Write a personalised safety plan with warning signs, coping, people, places, crisis services and emergency actions.
  2. 2Secure or remove relevant means and reconcile medicine quantities with the young person and safe carers.
  3. 3Confirm supervision, transport, home safety, wound care and a definite receiving appointment with information transfer.
  4. 4Actively respond to missed follow-up and provide a direct route back for worsening thoughts, new injury or unsafe circumstances.

Complications

01

Medical toxicity or disability

Overdose, blood loss, infection, nerve or tendon injury, scarring and organ damage may emerge after initially minor-seeming symptoms.

02

Repetition and suicide

A self-harm episode predicts further self-harm and increased suicide risk, especially when underlying drivers and access to means remain unchanged.

03

Trauma and stigma

Punitive responses, invalidation, restraint and visible scarring can increase shame, avoidance of care and future secrecy.

04

Family and educational disruption

Fear, conflict, missed school, peer exposure and uncertain supervision can destabilise recovery unless explicitly addressed in the care plan.

Monitoring and follow-up

  • Repeat intent, access to means, agitation, intoxication, psychosis and ability to use the safety plan after any change in environment or observation level.
  • Continue method-specific physical observations and blood tests for the full toxicology or injury interval rather than stopping after psychosocial assessment begins.
  • At follow-up, review self-harm frequency, urges, suicidal thinking, sleep, substances, treatment engagement, school and current interpersonal or online triggers.
  • Check that means-safety actions were practical and maintained, including medicine quantities and storage, without turning the home into punitive surveillance.
  • Track referral receipt, first contact and missed appointments, with named responsibility for active outreach during high-risk transitions.
  • Reassess safeguarding and carer capacity whenever the young person reports punishment, rejection, violence or increased concealment after disclosure.

Special situations

Direct questions are protective

Clear enquiry about suicide, method and intent helps disclosure and planning; it does not implant suicidal thoughts.

Function and intent can coexist

An episode may regulate emotion and include a wish to die, so forcing it into one category loses clinically important information.

Formulation should change action

Each identified driver or protection should connect to supervision, therapy, means safety, safeguarding or a practical support step.

Transitions need active ownership

Leaving emergency care, inpatient units or crisis services can increase vulnerability when appointments and responsibility are vague.

Kindness affects future disclosure

Pain relief, respectful wound care and non-shaming language make it more likely the young person will seek help before a later crisis escalates.

Common pitfalls

  1. 01

    Calling the young person low risk because they deny current intent after the crisis environment changes.

  2. 02

    Using a risk score or traffic-light category to decide discharge, observation or access to treatment.

  3. 03

    Delaying physical treatment while waiting for mental-health assessment or assuming calm behaviour excludes delayed toxicity.

  4. 04

    Demanding a no-suicide contract instead of developing a specific collaborative safety and means-restriction plan.

  5. 05

    Sending the young person home with a generic crisis number but no confirmed supervision, appointment or information transfer.

  6. 06

    Involving family without checking whether disclosure could lead to violence, rejection, coercion or loss of housing.