E036 · Emotional experience & regulation
Self-harm
What must adults understand and do when a young person may be intentionally harming themselves, has thoughts of self-harm, or may not be able to stay safe?
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Overview
Self-harm means intentional self-poisoning or injury, irrespective of the apparent purpose. People may self-harm for different, changing or unclear reasons. Self-harm is not the same as suicidal intent, but the two can overlap and both require direct, compassionate assessment.
This is a direct safety route, not a subsection of challenging behaviour. A young person should not have to be disruptive, disclose perfectly or use particular words before adults respond. E017 covers broader behaviour that creates safety concerns; this page addresses intentional self-harm and associated thoughts.
NICE's self-harm guideline does not cover repetitive or stereotyped self-injurious behaviour. Such behaviour still requires a serious response to injury, pain, communication, sensory, developmental and safeguarding needs, but the formulation and support route may differ.
If there is immediate danger, serious injury, suspected poisoning or overdose, active suicidal intent, or the young person cannot be kept safe, call 999 or go to A&E. For urgent mental-health help in England, use NHS 111 online or call 111 and select the mental-health option. Follow the setting's safeguarding and emergency procedures.
The useful question is never:
“Are they doing this for attention?”
It is:
“What has happened, what do they need medically and emotionally right now, and who must act to keep them safe?”
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What this might look like
A young person might:
- disclose self-harm directly or indirectly;
- talk about urges, thoughts, plans or feeling unable to stay safe;
- have injuries or physical symptoms needing medical attention;
- wear clothing or avoid activities in ways that conceal injury;
- seek information about self-harm or death;
- become markedly more withdrawn, agitated, hopeless or impulsive;
- give away valued possessions or make unusual goodbyes;
- show sudden changes in sleep, eating, attendance or self-care;
- use substances or take other risks alongside self-harm;
- ask a friend to keep a dangerous secret;
- communicate through writing, art, online activity or another person;
- deny or minimise harm because of fear, shame or consequences;
- continue attending and achieving while risk remains significant;
- have self-harmed without wanting to die;
- have suicidal thoughts without having self-harmed;
- move between different levels of intent and safety over time.
None of these signs establishes what happened. They are reasons to listen, check immediate needs and follow the appropriate pathway. Absence of visible injury does not establish safety.
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How this may change through development
At this stage
Early childhood
Intentional self-harm as defined here is less commonly identified in young children, and intent may be difficult to establish. Any injury, poisoning, concerning statement or sudden behavioural change requires developmentally informed medical and safeguarding assessment. Repetitive self-injury, accidents and communication of pain need their own formulation rather than assumption.
Early childhood
Intentional self-harm as defined here is less commonly identified in young children, and intent may be difficult to establish. Any injury, poisoning, concerning statement or sudden behavioural change requires developmentally informed medical and safeguarding assessment. Repetitive self-injury, accidents and communication of pain need their own formulation rather than assumption.
Middle childhood
Children may use indirect language, imitate material they have encountered or struggle to distinguish thoughts, urges and actions. Adults should respond calmly, involve safeguarding leads and seek age-appropriate health or mental-health advice rather than dismissing the concern because of age.
Early adolescence
Risk can interact with peer relationships, bullying, identity, online exposure, mood, trauma and impulsivity. Friends may become the first recipients of disclosure and need support. Secrecy, shame and fear of losing control over information can block help-seeking.
Later adolescence
Access to substances, travel and greater independence may change opportunity and risk. Planning must coordinate education, family or carers where appropriate, health services and the young person's growing autonomy, with explicit arrangements for crises and transitions.
Choose each stage to see how the presentation and surrounding expectations may change over time.
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Strengths and differences
A young person who self-harms may also show:
- courage in surviving and disclosing distress;
- insight into triggers, functions and warning signs;
- strong relationships, values, interests and future hopes;
- effective coping strategies that can be strengthened;
- care for friends and family;
- willingness to collaborate on a safety or care plan;
- a clear sense of what responses increase or reduce danger.
Strengths and protective factors matter, but they do not cancel risk. They should inform a collaborative plan rather than reassure adults into inaction.
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Top tips for support
Act on immediate medical need first
Establish the severity of injury, possible poisoning, consciousness, pain and immediate danger. Use emergency services or urgent healthcare as indicated. Do not delay medical care while trying to determine motive.
Stay calm and direct
Listen without shock, anger, interrogation or moral judgement. Use clear questions within your role and procedure. Asking about self-harm and suicide is part of appropriate assessment; avoiding the subject does not create safety.
Do not promise secrecy
Explain that information will be shared only with people who need to help keep the young person safe. Follow the child-protection policy and contact the designated safeguarding lead or deputy immediately.
Do not leave safety to the young person or a peer
Ensure appropriate supervision and handover according to the situation and plan. A friend should never be made responsible for monitoring risk.
Preserve dignity and communication
Offer a private space, chosen communication mode and one consistent lead where possible. Do not require repeated disclosure to multiple adults.
Seek specialist assessment
Self-harm requires a psychosocial assessment by an appropriately skilled mental-health professional, alongside physical healthcare. School staff should not replace this with a checklist or their own risk category.
Build and follow a coordinated plan
With the young person and relevant professionals, identify warning signs, supportive people, coping options, access to help, environmental safety, education adjustments and what happens if risk increases.
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Things needing careful planning
The immediate response should establish, as soon as possible and within role:
- severity of injury and urgency of medical treatment;
- possible poisoning or overdose;
- current emotional state and distress;
- immediate concern about safety or suicide;
- safeguarding concerns;
- whether a care or safety plan exists;
- which specialist service or professional must be contacted.
The education setting needs a current policy, a designated lead, trained staff, clear recording and information-sharing arrangements, and a route for supporting close friends or peers. A support plan should be developed with the student, family or carers as appropriate, and involved mental-health professionals.
Do not use risk-prediction scales or global labels such as low, medium or high risk to decide who receives care. Needs, immediate and longer-term safety, strengths and context require individual assessment and formulation.
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Practical support principles
A useful self-harm response has five parts:
1. Urgency — obtain emergency or medical care when needed. 2. Safety — follow safeguarding procedures and establish immediate protection. 3. Assessment — connect the young person with age-appropriate psychosocial and mental-health assessment. 4. Coordination — agree roles, information sharing, education adjustments and crisis routes. 5. Continuity — maintain compassionate contact, review the plan and respond to recurrence without blame.
Success is not the absence of disclosure. Help-seeking, honest communication and timely use of a plan are positive safety outcomes. Recovery may be non-linear.
From understanding to support
Relevant Phoenix Atlas approaches
| Approach | Fit | Why |
|---|---|---|
| A003 Co-regulationAtlas record available | Supportive only | A calm, trusted adult can help the young person remain connected while emergency, safeguarding and clinical pathways are activated. |
| A017 Communication partner strategiesAtlas record available | Supportive only | Helps adults listen, explain information sharing and provide accessible ways to disclose or seek help. |
| A005 Environmental adaptationAtlas record available | Supportive only | May reduce identified school stressors and support an agreed safety plan; changes must be individual and coordinated with professionals. |
| A002 Emotion CoachingAtlas record available | Context dependent | May support recognition and communication of distress outside acute crisis, but it is not an assessment or treatment for self-harm. |
| A001 Low-arousal approachesAtlas record available | Context dependent | Calm, non-confrontational interaction may reduce immediate escalation while proper help is obtained; it must not minimise urgency. |
No Phoenix Atlas approach is a treatment for self-harm or a substitute for medical care, safeguarding action, psychosocial assessment or specialist mental-health support.
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Evidence and cautions
NICE defines self-harm as intentional self-poisoning or injury irrespective of apparent purpose. It recommends that a non-health professional establishes medical urgency, emotional state, immediate safety, safeguarding concerns, existing plans and need for specialist referral as soon as possible.
NICE recommends that educational settings have policies and procedures, a designated lead and staff who know how to act. Following self-harm, the designated lead should seek mental-health advice for a support plan with the student and family or carers as appropriate. Close friends and peer groups may also need support.
NICE advises against using risk scales to predict future suicide or repetition, or using global risk categories to decide treatment or discharge. A needs-based psychosocial assessment and collaborative safety planning are different from a numerical prediction.
Keeping Children Safe in Education 2026 requires school and college staff to follow their safeguarding procedures. Where a mental-health concern is also a safeguarding concern, the designated safeguarding lead or deputy must be involved according to the setting's policy.
Source notes
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Explanatory lenses
Self-harm may occur alongside depression, anxiety, trauma, eating disorders, substance use, psychosis, neurodevelopmental differences, bullying, abuse, exploitation, discrimination, pain, family stress and other mental or physical health needs. No single diagnosis or motive explains every episode.
Self-harm without stated suicidal intent still warrants serious assessment. Suicidal thoughts can occur without self-harm. Intent and safety can change, so the response must not depend on a permanent label.
Repetitive or stereotyped self-injury may have different sensory, communication, pain or developmental functions and falls outside NICE's self-harm definition. Injury and safety still require action, with a formulation suited to that presentation rather than a behavioural judgement.
The continuing Phoenix question is:
“What must happen now for medical safety, safeguarding and compassionate connection—and who is responsible for each next action?”
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