Paeds · mental-behavioural-and-psychosomatic
Child and adolescent suicide and self-harm assessment
Also known as Suicidal ideation assessment · Suicide risk assessment · Self-harm assessment · Non-suicidal self-injury assessment · Safety planning · Means restriction counselling
A fellowship approach to assessing suicide risk and self-harm in children and adolescents: distinguishing non-suicidal self-injury from suicidal self-harm; structured risk stratification using ideation, plan, intent, means access and prior attempts; co-building a Stanley-Brown safety plan; means restriction counselling with carers; and disposition matched to dynamic risk across ANZ, UK, US and Canada.
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Target exams
Red flags
- Active plan plus intent plus access to means — imminent risk, do not discharge alone
- Recent suicide attempt, especially by high-lethality method (hanging, firearm, large overdose)
- Disclosure that the young person cannot guarantee their own safety until next contact
- Acute intoxication, psychosis or severe agitation with suicidal ideation
- Sudden 'calm' after a period of despair in someone with a plan — re-assess, do not reassure
- Discharge against advice or absconding from a person with active suicidality
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Adolescent health and mental health: suicide risk and self-harm assessment
- Current 2026 PREP curriculum — Learning Objective 1.2.1: Communicate with a child or young person in a way which is appropriate to the position of that child within their own culture
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Child and adolescent mental health — suicide risk assessment and safety planning
- Clinical Applications
- Mental health emergencies: suicide risk and self-harm assessment
- Long Cases
- Short Cases
- Communication stations
- 8. Safeguarding and social paediatrics
- 11. Adolescent health
- 10. Mental health and behavioural problems
- General Paediatrics: Assesses suicide risk and self-harm, co-builds a safety plan and arranges appropriate disposition
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Mental health, safeguarding and adolescent risk assessment
- Communication
- History
- Clinical
- Development
- General Pediatrics Content Outline — Domain 6: Behavioral and Mental Health
- General Pediatrics Content Outline — Domain 11: Adolescent Medicine
- General Pediatrics EPA 3: Assessing and managing mental health concerns including suicide risk
- Patient Care 5: Patient Management
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Professionalism 1: Professional Behavior and Ethical Principles
- Systems-Based Practice 3: System Navigation for Patient Centered Care - Coordination of Care
- Communicator
- Collaborator
- Health Advocate
- Pediatrics: Foundations EPA — Assessing and managing mental health needs including suicide risk in children and adolescents
Overview & Definition
A 14-year-old is brought to the emergency department after taking a handful of paracetamol tablets during an argument with a parent. A 16-year-old in your clinic quietly shows you fresh cuts on her forearm and asks you not to tell anyone. A 12-year-old, asked how he is feeling after a friendship breakdown, says, "Sometimes I wish I was dead." These are not rare presentations. They are the everyday work of paediatrics, and the skill they test is suicide and self-harm assessment. [3] [4]
Suicidal ideation means thoughts of ending one's own life. It ranges from passive ("I wish I could go to sleep and not wake up") to active ("I think about killing myself"). A suicide attempt is self-directed behaviour with at least some intent to die, regardless of medical lethality. Suicide is death caused by self-directed injurious behaviour with intent to die. Self-harm is intentional self-injury or self-poisoning regardless of motivation — and this umbrella term deliberately includes both suicidal and non-suicidal acts. [3] [4]
The single most important distinction in this topic is between non-suicidal self-injury (NSSI) and suicidal self-harm. NSSI is deliberate self-inflicted damage to the surface of the body — cutting, burning, hitting — undertaken to relieve an intolerable affect, without intent to die. Suicidal self-harm carries intent to die. The distinction matters because the function, the short-term risk and the management differ — and because mixing them up at the bedside leads either to dangerous under-reaction or to frightened over-hospitalisation. [7] [18]
The skill here is not predicting who will die by suicide — no tool can do that. It is running an encounter where a young person feels safe enough to tell you the truth, stratifying their acute risk honestly, and acting on it with a plan the young person and their carers can own. [15] [3]
References21ShowHide
- [1]Posner K The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. The American journal of psychiatry, 2011.PMID 22193671
- [2]Horowitz LM Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of pediatrics & adolescent medicine, 2012.PMID 23027429
- [3]Shain B Suicide and Suicide Attempts in Adolescents. Pediatrics, 2016.PMID 27354459
- [4]Bridge JA Adolescent suicide and suicidal behavior. Journal of child psychology and psychiatry, and allied disciplines, 2006.PMID 16492264
- [5]Liu RT Prevalence and Correlates of Suicide and Nonsuicidal Self-injury in Children: A Systematic Review and Meta-analysis. JAMA psychiatry, 2022.PMID 35612875
- [6]Gillies D Prevalence and Characteristics of Self-Harm in Adolescents: Meta-Analyses of Community-Based Studies 1990-2015. Journal of the American Academy of Child and Adolescent Psychiatry, 2018.PMID 30274648
- [7]Nock MK Self-injury. Annual review of clinical psychology, 2010.PMID 20192787
- [8]Rasmussen S Why Do Adolescents Self-Harm? Crisis, 2016.PMID 26831210
- [9]Cybulski L Risk factors for nonfatal self-harm and suicide among adolescents: two nested case-control studies conducted in the UK Clinical Practice Research Datalink. Journal of child psychology and psychiatry, and allied disciplines, 2022.PMID 34862981
- [10]Qian J Risk of repeat self-harm and suicide death following an episode of hospital self-harm presentation among adolescents and young adults. Journal of affective disorders, 2023.PMID 36280199
- [11]Horowitz LM Implementing Suicide Risk Screening in a Pediatric Primary Care Setting: From Research to Practice. Academic pediatrics, 2022.PMID 35248306
- [12]Kemper AR Depression and Suicide-Risk Screening Results in Pediatric Primary Care. Pediatrics, 2021.PMID 34099503
- [13]Bandealy A Use of lethal means restriction counseling for suicide prevention in pediatric primary care. Preventive medicine, 2020.PMID 31644896
- [14]Siry BJ Lethal means counseling for suicide prevention: Views of emergency department clinicians. General hospital psychiatry, 2021.PMID 33971519
- [15]Albaum C Safety Planning Interventions for Suicide Prevention in Children and Adolescents: A Systematic Review and Meta-Analysis. JAMA pediatrics, 2025.PMID 40388177
- [16]Mehlum L Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry, 2014.PMID 25245352
- [17]Kothgassner OD Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis. Psychological medicine, 2021.PMID 33875025
- [18]Ougrin D Adolescents with suicidal and nonsuicidal self-harm: clinical characteristics and response to therapeutic assessment. Psychological assessment, 2012.PMID 21859219
- [19]Witt KG Interventions for self-harm in children and adolescents. The Cochrane database of systematic reviews, 2021.PMID 33677832
- [20]Cottrell D Reducing self-harm in adolescents: the RISA-IPD individual patient data meta-analysis and systematic review. Health technology assessment (Winchester, England), 2024.PMID 39024118
- [21]Bridge JA Suicide Trends Among Elementary School-Aged Children in the United States From 1993 to 2012. JAMA pediatrics, 2015.PMID 25984947