Upon reflection, probably the single biggest request that we hear from providers in the field is a desire to use CAMS with adolescents and even young children who are suicidal. As a treatment researcher, this demand has been challenging because we simply do not yet know the full impact of CAMS on youth based on randomized controlled trials (RCTs) with replicated results and independent validation. While we do have excellent RCT data supporting CAMS for adults and supportive data with older adolescents who are in college, we do not yet have extensive data on younger teens or children who are suicidal.
Research so far on using CAMS with youth
So what do we know empirically so far? In our college student Randomized Control Trial (Pistorello et al., 2020) the average age of patients receiving CAMS was 19 and we saw significant reductions in suicidal ideation and overall symptom distress caused by CAMS (when compared to usual care). We also saw significant reductions in hopelessness for certain students in comparison to control care. We also know from Dr. Amy Brausch’s psychometric research that the Suicide Status Form (the SSF is the key multipurpose tool used in CAMS) is both valid and reliable when used with adolescents who are suicidal. Several published papers about the use of the SSF and CAMS with teens and even children have appeared over the years. Under the leadership of Dr. Molly Adrian, we have recently published a small clinical trial of CAMS with teens at Seattle Children’s Hospital showing positive effect sizes related to reducing suicidal ideation and showing that using CAMS was both feasible and acceptable to both adolescent patients and their providers.
The scientist in me says wait; the clinician in me says proceed with caution
But the dilemma for me has been related to promoting the use of “CAMS-4Teens” prior to having robust and supportive RCT findings (along with replication of RCT results and independent validation by other clinical researchers). The good news is that there are now three funded NIMH RCTs of CAMS that will help provide those exact outcome results. The bad news is that such data will not be published for 5-7 years at the earliest. Clearly, clinical trial research proving a treatment actually works—and is not harmful—is a painstaking process and not for those who are inpatient for such results! So, do we deny the use of CAMS for another several years awaiting the findings of funded and well-powered RCTs? The scientist in me says let’s wait. But the clinician/pragmatist in me says let’s proceed with caution promoting its use based on what we know from research thus far and our best recommendations about what is likely to work going forward. And to this end, we actually know a fair amount and we are now moving ahead to train clinicians in CAMS-4Teens as best we can based on what we know so far.
Promising data for evidence-based treatments for youth
One thing that I will note is that we see promising data in some suicide-focused “cousins” to CAMS that providers may consider using. There are good data (sometimes mixed but overall supportive) for using Dialectical Behavior Therapy (DBT) with adolescent populations (developed by Dr. Marsha Linehan). In addition, I am a fan of Dr. Guy Diamond’s Attachment Based Family Therapy (ABFT) which has decent RCT support for reducing suicidal ideation among teens within Guy’s lab (independent RCT replication is pending). But beyond these two approaches there is little else available that has robust RCT support.
Three funded RCTs are in progress using CAMS with youth
In terms of CAMS, I have frankly have little to no concerns about using the framework with teenagers. Along with other colleagues I have used CAMS for years with youth and seen how powerful this patient-centric, suicide-focused, intervention can be for adolescents who are suicidal. Beyond our “CAMPUS” clinical trial, two new RCTs specifically focused on teens show tremendous promise thus far. The first is the “Keta-CAMS” RCT being conducted at the Cleveland Clinic and Mass General Hospital. This RCT randomizes inpatients who are acutely suicidal following a suicide attempt. Half of the sample receive 1 to 6 intravenous does of Ketamine (the control sample receives IV doses of saline) and all patients in the trial receive an initial session of CAMS-4Teens prior to discharge and up to 7 more outpatient sessions of CAMS via telehealth (during the high risk post-discharge period). This study is intended to test a potential synergistic effect of an active medication which may enhance the clinical impact of CAMS (as compared to placebo control). The second major NIMH-funded RCT is called “ASSIST” which randomizes outpatient teens who are suicidal (at Seattle Children’s Hospital and Nationwide Hospital in Columbus OH) to either CAMS-4Teens vs. Safety Planning + (developed by Drs. Barbara Stanley and Greg Brown) vs. treatment as usual. Both of these multisite RCT’s are just now starting up and we have hammered out some procedures, particularly related to parents, that are important to share at this early juncture.
How do we best involve parents?
As a patient-centered intervention, CAMS philosophy requires that the teenager is the focus of all clinical care. To this end, we aim to discourage “back door” discussion with parents that do not include the adolescent patient. It is critical for the child to perceive the CAMS clinician as THEIR provider, not their parent’s. We see this as an essential dynamic which is designed to win the trust of the adolescent patient. In other words, if the teen sees their clinician is communicating everything they share with the parents (without their being privy to such discussions) they will naturally be less candid with their provider. However, to varying degrees, clinicians in these two RCTs are ambivalent about not having a separate line of parent-only communications. In turn, parents might feel left out or threatened by not know what is going on with their child and teens may fail to disclose key information that may be crucial for the provider to know. What to do? How do we earn the child’s trust but still get parental buy-in and support of the treatment which by its nature will be defined by the child-patient’s perceptions and needs vs. the parents’ agenda for their child? How do we secure lethal means in the family home that may occur better as a separate conversation with parents vs. the child being made aware of potential dangers in the home about which they may not know? Through some hard discussions, I believe we have landed on initial answers to all these key questions.
The role of the parents supporting their child’s treatment
First up, there needs to be a parent-only engagement, before engaging the teen in their first session of CAMS. In other words, CAMS-4Teens in these trials will begin with a parent-only meeting to help orient them to the intervention, set expectations, and provided guidance for their role in their child’s care. This 15-20-minute discussion makes the following clear: as your child’s provider, I have the suicide issue that will be our singular focus within this treatment. In turn, your job as parents is to support this suicide-focused treatment that is designed to save your child’s life! The discussion then shifts to ensuring that the home environment is made as safe as possible. This involves the use of a new tool called the “Stabilization Support Plan” which methodically reviews potential access to firearms, medications, and any other lethal means in the home environment. Once this lethal means discussion has occurred and all questions have been addressed, the parents leave and the teen comes in for the first session of CAMS. Following completion of the end of the first session of CAMS, the parents are brought back to rejoin the clinician and their child to review the teen’s treatment plan including their CAMS Stabilization Plan and the two problem/drivers of suicide and interventions that will be used to treat these drivers. The second page of the Stabilization Support Plan is then completed with parents and the teen as to how the parents can best support/engage their child if a suicide crisis occurs. We thus allocate 1.5 hours for this critical first session; thereafter parents will be engaged at the end of each interim session to review the work and address questions as well as playing a key role towards the end of the final outcome disposition session as well. Across CAMS-guided care, we discourage the parents from trying to communicate separately with the provider (but for unusual or emergent issues) to minimize any perception of a back-door level of communication that does not include the child-patient.
I am quite pleased with the negotiations and compromises that we made to work out this protocol for working with parents, which to me has always been the “wild card” of working clinically with youth. Sometimes parents are the greatest resource and ally for care you can have; other times, parents can undermine, fight, or even sabotage their child’s care (often because of fear, embarrassment, and feeling out of control). I am pleased to note that we have recently filmed extensive video demonstrations of this protocol for working with parents and teens in unrehearsed/unscripted role plays. Our teen actors played characters based on peers they know and our amazing CAMS consultants were the adults playing parents. This new material is in the spirit of previous video demonstrations of “real world” issues that come up in clinical work with people who are suicidal, and this new training material will not disappoint!
Threading the needle between RCT support and the need to save young lives
Bottom line, as the RCTs march forward, we are not shying away from providing our best possible training guidance for using CAMS with young people who are suicidal. We are attempting to thread the needle of being fully informed by RCT evidence that has not yet been realized vs. the real-world needs of clinicians, parents, and teens to do something effective in the face of losing adolescents to suicide. Stay tuned for more research to come on CAMS-4Teens and for our foray into providing the best evidence and clinical practices for working effectively with this leading cause of death for our precious youth.