Child and adolescent suicide and self-harm assessment — formative SAQs

SAQ 1 — Self-harm assessment and risk stratification (10 marks)

A 15-year-old girl presents to the emergency department after taking an overdose of paracetamol following a relationship break-up. She has superficial lacerations on her forearms. She is medically stable. ^{[3] [4]}

Questions

1. Outline how you would classify this presentation and distinguish non-suicidal self-injury from a suicidal attempt. (3 marks) ^[7]
2. Describe the structured assessment you would perform to stratify her suicide risk. (5 marks) ^[1]
3. State the key elements of the disposition plan and the follow-up you would arrange. (2 marks) ^[3]

Model answer

Classification (3). Self-harm is intentional self-injury or self-poisoning regardless of motivation. The branch point is intent, not lethality. Non-suicidal self-injury is deliberate tissue damage (cutting) undertaken to relieve distress without intent to die. A suicidal attempt carries intent to die, even if ambivalent and even if the medical lethality is low. Ask directly: "When you took the tablets, were you trying to die?" A low-lethality overdose taken with clear intent is a suicidal attempt; deep wounds inflicted purely for affect relief are NSSI. Both raise future suicide risk, so neither is dismissed. ^{[7] [3]}

Structured assessment (5). Build rapport in a private space, state conditional confidentiality, and ask directly. Stratify using the C-SSRS dimensions: severity and recency of ideation (passive versus active); presence of a plan and its specificity; intent to act; access to means (can she get to more tablets or to a method she has considered); and any history of prior attempts — the single strongest predictor. Take the precipitant (the break-up), the function of the lacerations, and screen for depression, anxiety, trauma, substance use and sleep. Assess protective factors (family, peers, school, reasons for living, help-seeking). Weigh risk against protection into low, moderate, high or imminent, and document the reasoning. Re-assess once medically stable and sober. ^{[1] [4]}

Disposition and follow-up (2). Match intensity to risk. Given the overdose and recent loss, arrange urgent mental-health review within 24 to 72 hours if she is assessed as moderate risk and can keep herself safe, with same-day carer involvement. Co-build a written safety plan and deliver means restriction counselling to her carer (secure medications, remove sharps). If she has plan, intent and means access or cannot guarantee her safety, do not discharge — use the crisis pathway and admit if she cannot be kept safe. Confirm the follow-up appointment was attended, because repeat and suicide-death risk persists for months. ^{[3] [8]}