Self-harm and Suicide Risk in Young People: A Call for Personalised Assessment

Self-harm affects roughly one in six adolescents and is a potent predictor of suicide. Yet the best-known risk-prediction tools correctly identify only a small minority of future suicides. Instead of relying on scores, clinicians should carry out compassionate, personalised assessments, followed by rapid follow-up and collaborative safety plans.

A Widespread Issue with Serious Consequences

Self-harm is common in adolescents, with a pooled lifetime prevalence of 17% among those aged 12–18 (Gillies et al., 2018). Methods include cutting, head banging, hitting, and self-poisoning. Self-harm is a strong predictor of suicide, which remains one of the leading causes of death among people aged 15–29 globally (WHO, 2021).

In the UK, self-harm presentations to general practice among those aged 10–24 have increased since 2010, with a particularly high incidence in girls aged 13–16 during the COVID-19 pandemic (Trafford et al., 2023). One study found that 85% of young people who self-harmed had consulted a GP in the year prior, and risk increased with the number of consultations (Cybulski et al., 2022).

Self-harm is a strong predictor of suicide

Why Risk Scores Fall Short

Despite their widespread use, risk assessment tools should not be used to predict future suicide or self-harm, according to NICE guidelines (NICE, 2022). This recommendation is supported by a meta-analysis showing a combined positive predictive value of only 6% for commonly used tools, including the Beck Hopelessness Scale (Carter et al., 2017).

A UK cohort study found that most patients who died by suicide within six months of a self-harm episode had been previously categorised as “low risk” using standard tools (Steeg et al., 2018). These findings illustrate the limitations of predictive scoring systems, which can provide false reassurance and may lead to inadequate care.

Although some clinicians find risk tools useful as quick references, they should not replace a comprehensive, individualised clinical assessment. A thorough evaluation involves identifying current distress, underlying mental illness, and contextual risk factors such as bullying, family conflict, substance use, or exposure to suicide-related media (Hawton et al., 2012). Identifying protective factors—like family support, school engagement, or faith—can help inform clinical decision-making.

Risk tools are widely used but poorly predictive-personalised clinical assessments are essential.

Shifting Focus to Meaningful Conversations

Clinicians are encouraged to engage in open, compassionate discussions with young people, using gentle and specific questions about suicidal thoughts and behaviours (Sinclair & Leach, 2017). For example, asking whether a young person has imagined “going to sleep and not waking up” may invite more honest dialogue.

Contrary to common concern, asking about suicide does not increase risk or introduce the idea to the young person. Evidence shows that such conversations can reduce distress and encourage disclosure. Beginning with general questions about wellbeing and gradually moving towards more specific language can make these discussions feel safer for both the clinician and the young person.

When suicidal thoughts are disclosed, it is important to explore their frequency, emotional impact, and whether any preparatory actions have been taken, such as making plans or giving away possessions. Suicidal intent can fluctuate rapidly before, during, and after a self-harm episode, and motivations often evolve over time. This variability highlights the need for ongoing assessment rather than relying on a single snapshot in time. Clinicians should also inquire about protective factors—such as supportive relationships, future goals, or religious beliefs—which can be reinforced in the care plan and future appointments.

When concerns arise, timely follow-up is crucial. NICE guidelines recommend that young people disclosing suicidal ideation or plans should be seen again within 48 hours, ideally by the same clinician (NICE, 2022). Continuity of care and clear documentation are essential components of effective support.

NICE recommends replacing risk scores with detailed, person-centred assessments and collaborative safety planning.

Developing Collaborative Safety Plans

Once suicidal thoughts or behaviours have been identified, the next step is to work collaboratively with the young person to promote their safety and support recovery. Developing a personalised safety plan is a key component of this process.

According to NICE guidance, safety plans should be created jointly with the young person, involving family members or carers where appropriate. These plans outline practical steps that the young person can take during periods of distress.

Key elements of a safety plan include:

• Recognising warning signs
• Identifying coping strategies
• Connecting with others for distraction and support
• Accessing professional help when needed
• Creating a safer environment

While high-quality evidence from randomised controlled trials is limited, safety plans are widely regarded as good clinical practice and may help reduce the repetition of self-harm. Plans should be practical, accessible to the young person, and available to healthcare professionals involved in their care.

Importantly, safety plans are dynamic documents that should be reviewed regularly and adapted as the young person’s circumstances and needs evolve.

A collaborative, evolving safety plan can be a vital tool in supporting a young person’s recovery and promoting their ongoing safety.

Final Thoughts

Self-harm among adolescents is prevalent and carries a significant risk of future suicide. Although widely used, risk assessment tools offer limited predictive accuracy and may mislead care decisions. Clinicians are encouraged to adopt a needs-based, personalised approach that centres on clinical judgment, open dialogue, and compassionate care.

Effective care for self-harm starts with personal, compassionate assessment, not risk prediction scores.

Where next?

ACAMH Topic Guide

References

• Mughal, F., Ougrin, D., Stephens, L., Vijayakumar, L., & Kapur, N. (2024). Assessment and management of self-harm and suicide risk in young people. BMJ, 386. https://doi.org/10.1136/bmj-2022-073515
• Carter, G., Milner, A., McGill, K., Pirkis, J., Kapur, N., & Spittal, M. J. (2017). Predicting suicidal behaviours using clinical instruments: Systematic review and meta-analysis of positive predictive values for risk scales. The British Journal of Psychiatry, 210(6), 387–395. https://doi.org/10.1192/bjp.bp.116.182717
• Cybulski, L., Martin, R. M., Kipping, R. R., Horwood, J., Anderson, E. L., Cornish, R. P., … & Gunnell, D. (2022). Clinical prediction of self-harm and suicide: A population-based case-control study. PLoS ONE, 17(6), e0268515. https://doi.org/10.1371/journal.pone.0268515
• Gillies, D., Christou, M. A., Dixon, A. C., Featherston, O. J., Rapti, I., Garcia-Anguita, A., & Villasis-Keever, M. (2018). 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, 57(10), 733–741. https://doi.org/10.1016/j.jaac.2018.06.018
• Hawton, K., Saunders, K. E. A., & O’Connor, R. C. (2012). Self-harm and suicide in adolescents. The Lancet, 379(9834), 2373–2382. https://doi.org/10.1016/S0140-6736(12)60322-5
• NICE. (2022). Self-harm: assessment, management and preventing recurrence. National Institute for Health and Care Excellence Guideline NG225. https://www.nice.org.uk/guidance/ng225
• Sinclair, J., & Leach, R. (2017). Asking about suicide in primary care: Tips from the front line. British Journal of General Practice, 67(665), 79–80. https://doi.org/10.3399/bjgp17X689833
• Steeg, S., Haigh, M., Webb, R. T., Carr, M. J., Kapur, N., & Bergen, H. (2018). The predictive value of risk scales following self-harm: Multicentre, prospective cohort study. The British Journal of Psychiatry, 213(2), 412–418. https://doi.org/10.1192/bjp.2018.134
• Trafford, A. M., Hayes, J. F., Broadbent, M., & Pitman, A. (2023). Rates and characteristics of self-harm presentations to general practice during the COVID-19 pandemic: A retrospective cohort study. BMJ Mental Health, 26, e300679. https://doi.org/10.1136/bmjment-2023-300679
• World Health Organization. (2021). Suicide worldwide in 2019: Global health estimates. Geneva: WHO. https://www.who.int/publications/i/item/9789240026643

About the author

Sophie Mizrahi is Content and Events Producer at the Association for Child and Adolescent Mental Health (ACAMH). She holds a BSc in Psychology and a Postgraduate Diploma in Vocational and Career Development from Favaloro University in Buenos Aires, Argentina. Her career spans community-based programmes, where she led initiatives to support individuals, particularly young adults, in navigating transitions and making informed decisions about their personal and professional aspirations. She has also contributed to digital mental health projects and AI startups, with a focus on research and the development of mental health products. Her work consistently centres on expanding access to evidence-based mental health resources for professionals and the wider public.