Child and adolescent suicide and self-harm assessment — branching viva

Stem

The examiner will test whether you can classify a self-harm presentation, stratify risk, plan and act under pressure. [1] [3]

Branch 1 — Classification

Examiner: A 14-year-old presents after an overdose. How do you classify the act — is it suicidal or non-suicidal? [7]

Strong answer: The branch point is intent, not lethality. I ask directly what they intended. Suicidal self-harm carries intent to die, even if ambivalent and even if the dose was medically low. Non-suicidal self-injury is deliberate tissue damage undertaken to relieve distress without intent to die. The method tells me about lethality and means access, not about intent. [7] [8]

Examiner: And if it is NSSI, is it harmless? [7]

Strong answer: No. NSSI predicts later suicide risk and repetition because it is reinforcing — it relieves affect in the short term. I would still assess for co-existing suicidal ideation and build alternative coping into a safety plan. [7]

Branch 2 — Structured risk stratification

Examiner: How do you stratify her current risk? [1]

Strong answer: I use the C-SSRS dimensions — ideation (passive or active, frequency, intensity, recency), plan (specificity), intent (commitment to acting), means access (can she get to the method), and history of prior attempts, the single strongest predictor. I weigh these against protective factors — family, peers, school, reasons for living, help-seeking — into low, moderate, high or imminent risk. Risk is dynamic; I re-assess at every contact. [1] [4]

Examiner: She says she feels calm now and regrets it. [3]

Strong answer: A sudden calm after a period of despair is a red flag, not a reassurance — it can signal a decision has been made. I re-assess plan, intent and means access rather than discharging on the calm. [3] [4]

Branch 3 — Safety planning and means restriction

Examiner: She is assessed as moderate risk and going home. What do you put in place? [6]

Strong answer: I co-build a written Stanley-Brown safety plan: recognise warning signs; internal coping strategies; social distraction; named help-seekers; crisis and professional lines; and make the environment safe. A 2025 meta-analysis supports safety planning for reducing suicide-related outcomes in young people. I arrange urgent mental-health review within 24 to 72 hours and same-day carer involvement. [6]

Examiner: What about the medications at home? [5]

Strong answer: I deliver means restriction counselling to the carer. Restricting access to lethal means saves lives because the impulse is often brief and method-specific. I ask the carer concretely to secure or remove medications including over-the-counter paracetamol, lock away sharps, and address any means relevant to the plan. I name the carer as the agent of this step. [5] [6]

Branch 4 — High-risk override

Examiner: On re-assessment she now describes a specific plan for tonight and has access to more tablets. [3]

Strong answer: That is imminent risk — plan, intent and means access. I do not discharge. I maintain constant observation, remove means, activate the crisis pathway, and admit if she cannot be kept safe in the community. I tell her what I must share and why, share the minimum necessary, involve her carer, and document the reasoning. [3] [2]

Examiner: She begs you to keep it confidential. [3]

Strong answer: Confidentiality is conditional, not absolute. Serious risk of harm to self crosses the threshold. I override ethically — tell her in advance, share the minimum necessary, and stay engaged so the breach does not become abandonment. [3] [2]

Examiner extras

• Asking directly about suicidal thoughts does not increase risk. [2]
• Universal screening (ASQ) in primary care and emergency settings is now expected; a positive screen triggers a full assessment. [2]
• DBT-A has randomised-trial evidence for repeated self-harm; therapeutic assessment reduces repetition. [8]
• Re-assess at every contact; risk is dynamic. [1]