Challenges of Assessing and Treating Youth Suicide: A Solution in CAMS-4Teens®

The news of rising teen suicide rates is difficult to ignore. Every few months, the media reports on another study that documents how much teen suicide rates have increased in the past 20 years. Rates jumped from 6.8 deaths per 100,000 people in 2000 to 10.6 deaths per 100,000 people in 2017.¹ Suicide is now the second-leading cause of death for 15- to 24-year-olds, with only motor vehicle accident deaths outnumbering it. Researchers have noticed trends in suicide rates among girls and young women increasing, as well as for young black men.^1,2

Researchers and mental health professionals are struggling to identify causes for these trends and to quickly identify effective prevention and treatment strategies to address this major public health concern. While many research studies report on trends in rates among certain gender and ethnic groups, it is extremely difficult to identify causes for rising suicide rates. Our best educated guesses about this alarming trend relate to added stress caused by:

• addiction in families (as seen in the opioid crisis),
• the use of social media and the associated feelings of inadequacy, loneliness, and the pressures of “keeping up” with friends,³
• lack of access to mental health resources in schools and communities,
• lack of suicide-specific training for mental health professionals, and
• evidence that the current generation of youth experience more depression, anxiety, and stress in general than prior generations⁴.

All of these issues combined with easier access of searching, finding, and being exposed to media that depict or offer information on suicide may be impacting the increase.

Obstacles to Treatment

A major obstacle to reducing the rise of suicide rates across all age groups is the lack of evidenced-based care available for individuals who are suicidal⁵. Funding for research on suicide treatment lags far behind other health issues. For decades, researchers and mental health professionals did not include suicidal individuals in studies that tested promising new treatments because it was considered too risky. These barriers have brought us to our current state of feeling far behind in terms of knowing what works best for treating suicide. The National Institute of Mental Health has identified research on suicide as an area of priority, and more studies are being funded to help evaluate what methods work best for prevention, screening youth for suicide risk, and finding the best possible treatments.⁶

There are many layers of prevention and treatment that can be implemented for youth suicide. Many states have suicide prevention centers within their public health departments, which are tasked with implementing prevention programs in communities and schools and training mental health professionals in their state on best practices for working with suicidal patients. Within schools, Signs of Suicide has been found to be an effective gatekeeper training program that teaches teens about recognizing suicide risk in their peers and the steps they should take to connect their friends with resources.⁷ The Good Behavior Game is a classroom-management system that is used for second-graders and focuses on minimizing aggressive and disruptive behavior, and amazingly has shown long-term reductions in suicidal behavior as kids move through adolescence.⁸

Existing Treatment Programs

From a treatment standpoint, few treatments specific to suicide exist that have been shown to provide best clinical care for suicidal teens. Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are both used for teens with suicide risk. CBT works well as a treatment for depression and anxiety-related disorders, and it can also be used to help someone understand their thoughts about suicide and their feelings of hopelessness.⁹ DBT specifically addresses self-harming behavior and teaches teens important coping skills to use in place of self-harm.¹⁰

Safety-planning interventions and crisis response plans are useful when used in conjunction with DBT or CBT, as they provide concrete steps for teens and their families to follow when the teen is in crisis or thinking seriously about suicide.^11,12

Advantages of CAMS with Youth and Teen Suicidality

Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic assessment and treatment framework that combines all elements from these treatments into one approach. First, CAMS provides a thorough risk assessment in the first session and uses the Suicide Status Form (SSF) to gather valuable information about a teen’s current experience and overall suicide risk.

With CAMS, the entire assessment approach is collaborative. The therapist sits next to the teen (if they are comfortable with it), encouraging the feeling that they are literally on the same page. Because many adolescents may be hesitant or suspicious of the treatment process, CAMS emphasizes transparency and empathy. Instead of a therapist sitting across from the teen with a clipboard and taking notes (that the teen can’t see) while asking questions, the teen is either writing their responses on the Suicide Status Form themselves (first page), or they are watching the therapist write down their responses (second page). The therapist and the teen write the treatment plan together, identify the top two drivers together, and create the stabilization plan together.

We have seen the CAMS approach work very well with teens (CAMS-4Teens), both in our own practices and with consultation and case presentations from other clinicians, as well as in research. A recent study found that the Suicide Status Form works just as well for assessing teen’s suicide risk as it does with adults. Teens in the study were able to understand and rate constructs like psychological pain, hopelessness, and self-hate in a way that was helpful to determining their overall level of distress and suicide risk.¹³

Once the therapist and teen identify the top two drivers for the treatment plan, the therapist explains what the goals and objectives will be, and which interventions they will use to help achieve those goals. Many teens have some version of self-hate as a driver for suicide. Therapists can make simple goals of decreasing self-hate and identify interventions to target that driver. Examples of interventions may be CBT interventions for increasing self-esteem or behavioral activation for getting teens out of the house and connected to the community and causes they care about (e.g., mentoring younger kids, animal shelters, volunteer work). Furthermore, elements from CBT, DBT skills, problem-solving, interpersonal therapy, and many other methods can be integrated into the CAMS Treatment® plan to target and treat drivers.

Especially for teens in an acute suicidal state, sometimes it is extremely helpful to first identify the problem. The CAMS Assessment® provides a guided walk-through of the teen’s life at that moment, and if a particular stressor or issue is uncovered as being related to the current suicidal thoughts, it can be addressed quickly in treatment. Teens can be overwhelmed with situational factors that feel unsurmountable. We have observed CAMS to be very useful in breaking down these factors into more manageable pieces that the teen can then recognize as treatable.

Tips for Using CAMS with Teens and Adolescents (CAMS-4Teens)

We have assembled some general tips for using CAMS with teens that may be helpful. Before making any major modifications to the Suicide Status Form (SSF) for use with teens, we decided to test it in its existing form. Our hunches were correct:  we discovered that CAMS does not need to be radically changed for use with youth (ages 12-17).¹³

However, other slight procedural recommendations are helpful to keep in mind. First, some youth may need slower pacing for the assessment. It may take more time to explain concepts like psychological pain and agitation. Also, it may take some time to think about how to explain these concepts in a variety of ways.

Second, if the assessment is taking longer than usual, it is beneficial to prioritize getting the stabilization plan completed and in place. As much as possible and practical, intensive outpatient treatment is the goal of CAMS. This is largely achieved by having a solid stabilization plan/safety plan in place. It is very helpful to identify any supportive adults in the teen’s life that they can list on their stabilization plan as someone they can contact in a crisis. You may need to be creative in identifying these adults (e.g., parents, older siblings, other relatives, coaches, pastors, school counselors, etc.).

Third, some youth may respond better with a “parallel assessment” in which you are still gathering the information for the SSF while they are engaging in some other activity (coloring, fidget toys, etc.).

The last tip is focused on how to work with parents and caregivers during the course of CAMS Treatment. It is essential that other adults in the teen’s life are aware of the stabilization plan, understand how to respond to the child in a crisis, and can help assure access to lethal means are limited. We recommend completing the SSF with just the teen present, and then inviting the caregivers into the session at the end to review the stabilization plan. Caregivers may have a wide variety of emotional reactions to their suicidal teen, and it’s important to provide education on suicide in general, and the process of CAMS. Parents and caregivers may need their own support via therapy or community support groups.

In Conclusion

Thus far we have confidence from recent research results that the SSF is appropriate for teens,¹³ and that CAMS is a promising evidence-based treatment for suicidal teens.^14,15 We know that CAMS is an effective treatment for adults,¹⁶ and that many clinicians are using CAMS with youth ages 12+ with success.

Our consultants provide on-going support to clinicians using CAMS with teens, and the overwhelming response from clinicians has been positive. They describe CAMS as useful with all types of teens – from those who are very expressive and talkative as CAMS helps organize their thoughts and feelings, to those who may be more reserved as CAMS allows them to express themselves through the SSF without needing to verbalize everything.

The next phase of CAMS-4Teens research includes randomized clinical trials (RCT), which are the gold standard in treatment research, to gather more evidence for the effectiveness of using CAMS with youth. We see a bright future in which CAMS will be available as an evidenced-base intervention for suicidal youth, a group for which having effective treatment will make a big impact and save lives.

1. 1. Curtin, S. C., & Heron, M. (2019). Death rates due to suicide and homicide among persons aged 10–24: United States, 2000–2017. NCHS Data Brief, no 352. Hyattsville, MD: National Center for Health Statistics.
   2. Miron, R., Yu, K-H., Wilf-Miron, R., & Kohane, I. S. (2019). Suicide Rates Among Adolescents and Young Adults in the United States, 2000-2017. JAMA, 321, 2362-2364.
   3. Twenge, J. M. (2017). Have smartphones destroyed a generation? The Atlantic, https://www.theatlantic.com/magazine/archive/2017/09/has-the-smartphone-destroyed-a-generation/534198/.
   4. Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E., & Binau, S. G. (2019). Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005-2017. Journal of Abnormal Psychology, 128, 185-199.
   5. Jobes, D. A., & Joiner, T. E. (2019). Reflections on suicidal ideation. Crisis, 40, 227-230.
   6. Research Prioritization Task Force. (2014). A prioritized research agenda for suicide prevention: An action plan to save lives. National Action Alliance for Suicide Prevention.

http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Agenda.pdf

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9. Jobes, D. A., Vergara, G. A., Lanzillo, E. C., & Ridge-Anderson, A. (2019). The potential use of CAMS for suicidal youth: Building on epidemiology and clinical interventions. Children’s Health Care, 48, 444-468.
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