Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Self-harm and suicide risk in adolescents
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
!
Treat injury and suicide danger together
Reduced consciousness, poisoning, major bleeding, strangulation, burns, high-energy trauma or another serious injury requires immediate emergency care; active suicidal intent, preparation, accessible lethal means, psychosis, severe agitation, exploitation or an unsafe home requires urgent mental-health and safeguarding action.
Action: Assess ABCDE and glucose, call emergency or toxicology support as indicated, treat injury without judgement, maintain observation proportionate to immediate danger, and request an age-appropriate psychosocial assessment as early as possible rather than waiting for all medical treatment to finish. Ensure a safe responsible handover and do not discharge before physical, psychological and safeguarding plans are agreed.
Overview
Respond compassionately to adolescent self-harm, treat physical injury or poisoning, complete a developmentally informed psychosocial and safeguarding assessment, formulate suicide risk without discredited scoring, and provide collaborative safety planning and rapid aftercare.
Self-harm is an action, not a personality label. Cutting, burning, hitting, strangulation, ingestion of medication or chemicals and other intentional injury can serve several functions, including reducing unbearable emotion, interrupting dissociation, communicating distress, self-punishment or attempting death. The same episode can have mixed or uncertain intent. Avoid terms such as attention seeking or manipulation; they obscure need, damage disclosure and can cause staff to undertreat pain or poisoning.
Medical and psychological care begin together. Establish what was taken or done, when, quantity, route, co-ingestion, symptoms and available packaging or photographs, while resuscitating as needed. Seek poison-information support through the proper clinical service and assess strangulation or other occult injury carefully. Do not make access to compassionate treatment conditional on an explanation. When sufficiently alert, the adolescent should be offered a private, age-appropriate psychosocial assessment even while medical care continues.
Practice
Two practice questions
Your practice draft is saved in this browser.
Question 1 of 2
0 correct
PsychiatryOriginal SBA
Risk-scale limitation
A 16-year-old is medically stable after self-poisoning. A screening scale labels future suicide risk as low, but the interview reveals stockpiled tablets and recent preparation. What should guide care?
Sources and review status4 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.
The psychosocial assessment constructs an individual formulation. Ask about the hours and days before the act, intention at the time, expected lethality, efforts to avoid discovery, rescue-seeking, current thoughts, future plans and access to means. Explore prior self-harm and attempts, depression, anxiety, psychosis, mania, eating disorder, neurodevelopment, sleep, pain, substances, trauma, abuse, bullying, sexuality or gender stress, peer and online influences, school, family conflict, caring roles and protective relationships. Speak with carers and other agencies where appropriate without losing the young person's account.
Prediction tools cannot solve uncertainty. NICE explicitly rejects risk scales and global low, medium or high labels for predicting suicide or deciding treatment and discharge. A risk formulation instead describes current drivers, foreseeable changes, vulnerabilities, protective factors and scenarios that would increase danger. It supports a concrete plan but does not claim certainty. A person who denies intent may still need urgent care when the episode was highly lethal, circumstances are unsafe or mental state is unstable.
Disposition follows needs. General-hospital admission may be appropriate when safeguarding or home safety is unresolved, the adolescent cannot engage because of distress or intoxication, or necessary assessment and planning cannot yet be completed. Before any discharge, ensure medical needs are addressed, psychosocial assessment is complete, relevant agencies have a joint plan, carers know what to do, medications and other means are made safer where feasible, and a named service owns follow-up. A written leaflet without an appointment is not a handover.
Safety planning is collaborative and specific. Identify personal warning signs, internal coping steps, distractions and safe places, people the young person can ask for help, professional and emergency contacts, and ways to reduce access to medication, blades, ligatures or other identified means. Include what supporters should notice and do, while avoiding coercive blanket searches that may reduce disclosure. Review the plan after every episode and when relationships, school, online exposure or treatment change.
Aftercare treats both the self-harm pattern and its context. NICE recommends timely psychological intervention appropriate to development and need, with family involvement when helpful and safe. Address coexisting disorders according to their guidance, but do not offer a drug merely to prevent self-harm. If ongoing safety concerns exist, make first aftercare contact within 48 hours of psychosocial assessment and use missed contact as a cue for active outreach proportionate to risk.
Key points
Self-harm means intentional self-poisoning or injury irrespective of the stated purpose; functions and suicidal intent can coexist and change between or within episodes.
Use calm, validating and direct language, address pain and privacy, and ask what happened before, during and after the act rather than demanding a single reason.
NICE says not to use risk scales to predict suicide or repetition, determine access to treatment or decide discharge, and not to classify global risk as low, medium or high.
A skilled psychosocial assessment explores function, current and future intent, means, mental disorder, trauma, substances, development, family, peers, education, online life, safeguarding, strengths and goals.
Do not postpone the mental-health assessment until every physical intervention is complete when the young person can engage; physical and psychosocial care should proceed in parallel.
Consider general-hospital admission when safety concerns, abuse or exploitation, incomplete safeguarding planning or inability to engage in assessment make discharge unsafe, not as a punishment for self-harm.
Create a personalised safety plan with warning signs, coping steps, supportive people and places, service contacts, emergency options and collaborative restriction of lethal means.
Aetiology
01
Emotion regulation
Injury may rapidly reduce overwhelming arousal, shame or numbness, reinforcing reuse despite pain and longer-term consequences.
02
Interpersonal and environmental stress
Conflict, loss, bullying, abuse, discrimination, exploitation and academic or caring pressure can precipitate episodes and restrict help-seeking.
03
Psychiatric and developmental vulnerability
Depression, trauma, psychosis, eating disorder, substance use, impulsivity and neurodevelopmental needs can interact with adolescent transitions.
04
Social learning and access
Peer behaviour, online method content, available medication and prior relief can influence method choice, capability and repetition.
Pathophysiology
1
Negative reinforcement
Immediate reduction in distress after injury strengthens the behaviour even when the person regrets physical and relational effects.
2
Acute cognitive constriction
High arousal, hopelessness, intoxication or dissociation narrows future thinking and makes lethal action seem like the only available escape.
3
Habituation to harm
Repeated exposure to pain, injury or suicide imagery may reduce fear and increase capability without making future intent predictable.
4
Dynamic context
Intent and access can change rapidly with conflict, online contact, substance use, discharge, sleep loss or loss of supervision.
Clinical features and red flags
Emotion-regulation self-injury
The act rapidly reduces intolerable affect or numbness but reinforces future use because short-term relief follows injury.
Suicidal self-harm
Intent, preparation, expected lethality, concealment, farewell behaviour or regret at rescue indicate that death was an important possible outcome.
Ambivalent or changing intent
A young person may simultaneously want distress to stop, hope to be found and accept death, with intention shifting after the act.
Contagion and online influence
Peer episodes, graphic content, method information or social reinforcement can shape timing and method without fully explaining individual distress.
Safeguarding-linked harm
Abuse, exploitation, coercion, bullying or an unsafe placement may precipitate harm and make the expected discharge destination dangerous.
Escalating pattern
Increasing frequency, medical severity, planning, secrecy, method lethality or reduced help-seeking suggests a changing formulation needing urgent review.
Red flags requiring action
A current suicide plan, preparatory acts, intent to die, regret at survival, rehearsing, concealment or immediate access to highly lethal means requires urgent senior formulation and containment.
Hanging or strangulation, significant overdose, deep wounds, uncontrolled bleeding,
The assessment produces a shared formulation and care plan, not a binary distinction between real and non-suicidal harm.
03Suicide and means enquiry
Why
Clarify current thoughts, plan, preparation, capability, expected lethality, rescue and access to identified methods.
Interpretation and limitations
Responses are combined with behaviour, context and mental state; denial does not erase objective evidence or dynamic change.
04Safeguarding and collateral review
Why
Assess home safety, abuse, exploitation, bullying, caring burden, online risk and available responsible adults.
Interpretation and limitations
Share the minimum necessary information without consent when required to prevent death or serious harm, documenting reasons and the young person's views.
05
Differential diagnosis
01
Accidental injury or poisoning
Unintentional exposure still requires full physical care, while ambiguity should be explored privately without accusatory questioning.
02
Stereotyped self-injury
Repetitive injury in autism or learning disability may have sensory, communication or pain functions and can coexist with suicidal distress.
03
Compulsive or body-focused behaviour
Skin picking, hair pulling and compulsions may cause tissue injury without the same intended function, requiring their own formulation.
04
Fabricated or induced presentation
Discrepant histories demand careful medical and safeguarding assessment rather than assuming deception or withholding necessary treatment.
Management
01Emergency presentationStabilise and engage in parallelFirst stepAn adolescent presents after self-poisoning or intentional injury or with current suicidal danger.+
1Treat airway, breathing, circulation, glucose, poisoning, bleeding, pain and hidden injury promptly and respectfully.
2Arrange age-appropriate psychosocial assessment as soon as the young person can participate, without unnecessary delay until medical treatment ends.
3Maintain a safe environment, communicate across medical and mental-health teams and activate safeguarding when return home or carer involvement may be unsafe.
02FormulationReplace scoring with understandingImmediate physical resuscitation is underway or complete and the young person can be interviewed.+
1Explore the sequence, function, intention, lethality, current and future thoughts, prior episodes, mental disorders, substances and online influences.
Complications
01
Occult physical injury
Delayed toxicity, tendon or nerve damage, infection and strangulation complications may emerge after an initially reassuring appearance.
02
Suicide and escalating lethality
Future episodes can involve greater planning, capability or lethal means even when earlier self-harm had little stated suicidal intent.
03
Traumatic healthcare experience
Judgemental language, inadequate analgesia, forced disclosure and unnecessary observation can intensify shame and deter future help-seeking.
04
Educational and family disruption
Repeated crises, secrecy and fear can interrupt school, strain carers and narrow supportive relationships without coordinated aftercare.
Monitoring and follow-up
Reassess intent, plans, means, mental state, intoxication and willingness to accept help whenever circumstances or observation level changes.
Track self-harm frequency and severity without treating absence of an episode as proof that depression, abuse or suicide risk resolved.
Review the safety plan after each episode, near miss, discharge, medication change, school crisis or change in home and peer support.
Confirm that aftercare contact occurred within the planned interval and use failed contact for proportionate active outreach, not administrative closure.
Monitor coexisting depression, anxiety, trauma, eating disorder, psychosis, substances, pain and neurodevelopmental needs through their own outcomes.
Document information shared, consent sought, safeguarding rationale, who received the handover and who owns the next action.
Special situations
Function and intent overlap
Relief-seeking and a wish to die are not mutually exclusive, and forcing one label can miss rapidly shifting suicide danger.
Kind care is clinical care
Analgesia, privacy, clear explanations and non-judgemental wound care improve disclosure and willingness to accept psychological help.
A score cannot discharge
Population associations do not predict one adolescent accurately enough to replace assessment, formulation and safe follow-up arrangements.
Means safety is collaborative
Supporters can supervise or reduce access to identified medicines and methods while preserving dignity and discussing substitution risk.
Non-attendance carries meaning
A missed high-priority follow-up may reflect shame, control, transport, family danger or deterioration and warrants curious outreach.
Common pitfalls
01
Describing an adolescent as attention seeking, manipulative or low risk because the injury appears superficial.
02
Delaying psychosocial assessment until all physical care is complete despite the young person being able to engage.
03
Using a suicide score or low, medium or high category to decide discharge or access to treatment.
04
Assuming denial of current intent cancels the lethality, preparation or unsafe context of the episode.
05
Discharging to a potentially abusive or exploitative environment before safeguarding planning is complete.
06
Giving crisis numbers without a personalised plan, named aftercare service, appointment and response to missed contact.
07
Prescribing a medicine solely to stop self-harm instead of treating identified coexisting conditions and context.
When ongoing safety concerns remain, NICE recommends initial aftercare within 48 hours of the psychosocial assessment, with responsibility explicitly assigned.
Do not prescribe a medicine specifically to reduce self-harm; identify and treat coexisting depression, anxiety, trauma, substance use or other disorders through their evidence-based pathways.
reduced consciousness
, seizure or severe pain requires emergency medical treatment even if the adolescent later minimises harm.
Psychosis, mania, intoxication, severe agitation, dissociation, hopelessness or rapidly changing intent can reduce the reliability of an apparently reassuring conversation.
Suspected abuse, trafficking, sexual exploitation, coercive control, bullying or fear of returning home may make routine discharge to carers unsafe and demands safeguarding action.
Repeated episodes, escalating lethality, stockpiling medication, online suicide content, anniversary stress or loss of support should alter formulation despite any low questionnaire score.
Risk formulation rather than scale
Why
Describe drivers, vulnerabilities, protective factors, foreseeable events and practical mitigation.
Interpretation and limitations
Do not translate a score into low, medium or high discharge categories; formulation informs but cannot guarantee prediction.
2
Assess development, neurodivergence, trauma, abuse, family, peers, education, identity, strengths and what help the young person would accept.
3EscalationWrite a dynamic formulation with specific escalation scenarios, avoiding global risk labels and making uncertainty explicit.
03Discharge and aftercareCreate an owned safety bridgeMedical and psychosocial teams are considering discharge from the acute setting.+
1Confirm physical care, psychosocial assessment, safeguarding decision, safe destination, carer understanding and collaborative means restriction.
2Give the young person a personalised safety plan and exact daytime and out-of-hours contacts in an accessible format.
3Name the follow-up team and appointment; when ongoing safety concerns persist, arrange initial aftercare within 48 hours and act on non-attendance.