Who You Treat: Teens & Adolescents

The United States is experiencing a national emergency in child and adolescent mental health. According to the recent Youth Risk Behavior Survey Data Summary & Trends Report: 2013–2023, surveying high school students, experiences of violence, poor mental health, and suicidal thoughts increased over the past decade. Today, suicide is the second leading cause of death for youth and young adults ages 10-24. In Colorado—a state with one of the nation’s highest suicide rates historically—the youth mental health crisis is especially severe. Only 22% of youth who have a mental illness are receiving care.

While the Office of Suicide Prevention (OSP) within the Colorado Department of Public Health and Environment has made significant strides in the state’s suicide prevention, intervention, and postvention efforts, a critical gap in pediatric mental health services remains. In response, Children’s Hospital Colorado (Children’s Colorado) is addressing the high number of children and adolescents experiencing suicidal thoughts, behaviors, and other mental health concerns that are overwhelming pediatric emergency departments and inpatient units.

The Pediatric Mental Health Institute (PHMI), a department within Children’s Colorado, developed a groundbreaking outpatient Crisis Services strategic plan to build a robust continuum of care for youth experiencing mental health crises, including suicidal thoughts and behaviors. The first initiative in this plan—the launch of a rapid-access, time-limited Crisis Clinic—is showing early success in transforming pathways to care for youth at risk for suicide. Enhanced by the Collaborative Assessment and Management of Suicidality (CAMS) Framework®, this innovative model is redefining crisis intervention and expanding access to timely, evidence-based treatment.

Housed on the University of Colorado’s (CU) Anschutz Medical Campus and in partnership with the CU Department of Psychiatry, the Crisis Clinic started seeing its first patients in June 2024. By blending models from leading thought partners across the nation, selecting the evidence-based Collaborative Assessment and Management of Suicidality (CAMS) Framework® to treat patients, and leveraging a multidisciplinary team approach, the Crisis Clinic is transforming mental health for youth across the state through accessible and tailored outpatient services, empowering patients and families in their fight against suicide.

As part of the growing youth mental health crisis in Colorado and across the nation, children and adolescents experiencing suicidal thoughts and behaviors often seek care at the emergency department. From there, providers typically refer them to inpatient psychiatric units or discharge them with recommendations for outpatient services. However, due to hospital boarding, long waitlists, insurance limitations, and other barriers to accessing care, patients and families often face difficulties navigating mental health systems and connecting to care.

In response to this complex crisis and the need for more rapid-access care pathways, Children’s Colorado took action through advocacy and coordinated strategic planning efforts. Under the leadership of Dr. Beau Carubia, child psychiatrist and Medical Director for the Consultation-Liaison/Emergency (CL/ED) Division; Dr. Anastasia Klott, child psychiatrist and Interim Associate Medical Director of Crisis Services; and Betsey Bucca, LCSW, Associate Clinical Manager of Consultative/Crisis, the experienced mental health providers at Children’s Colorado came together to create something different. Dr. Collette Fischer, psychologist, joined the team as the Interim Program Director of Crisis Services, and in collaboration with process improvement specialists, the team worked to design and implement new models of care.

Their broad Crisis Services strategic plan takes a comprehensive, three-pronged approach to bridge mental health care gaps, integrating rapid-access outpatient care, enhanced emergency department triage, and short-term inpatient stabilization to ensure youth receive timely, individualized support.

Their vision was to first launch the rapid-access Crisis Clinic to provide immediate, evidence-based suicide-focused treatment in an outpatient setting for patients who neither required higher levels of care nor had an established mental health provider. Borrowing inspiration and guidance from other leading institutions nationwide, they developed a flexible, holistic approach that would meet the unique needs of each child.

The Crisis Clinic narrowed its focus to serving youth experiencing suicidal ideation and attempts. Today, the Crisis Clinic serves youth ages 10-17 who experience a range of suicidal ideation, from distressing thoughts to plans and attempts.

As part of a multi-year project to implement the Zero Suicide framework across all clinical sites and levels of care at Children’s Colorado, leaders of the Crisis Clinic selected the CAMS Framework for its effectiveness and adaptability. Dr. Fischer, Dr. Klott, Dr. Carubia, and Dr. Jessica Hawks, Clinical Director and incoming Chief of Psychology, were familiar with these models from their research on system-wide transformation and patient-centered care. Additionally, they were familiar with the CAMS Framework based on discussions with a former colleague, and now current faculty at the University of Washington, Dr. Eileen Twohy. “CAMS was the best fit given the amount of evidence backing it,” explained Dr. Klott.

When they explored CAMS further, they discovered that they could tailor the framework to each patient’s unique needs, which aligned seamlessly with their strategic vision. The framework consists of first gathering information about a patient’s experiences and suicide risk, followed by developing a treatment plan, a stabilization plan, and treating patient-identified “drivers” (the problems that compel the patient to consider suicide). Dr. Fischer added, “Because CAMS is a framework, it allows for flexible treatment planning, helping us remain focused on reducing suicide by addressing those unique drivers.”

The Crisis Clinic prioritizes education about the CAMS Framework and its approach to ensure families understand the care model. Alongside partners at OSP, over 40 providers across their network of care participated in the CAMS training. Additionally, Crisis Clinic providers have completed training in CAMS-4TeensⓇ and CAMS Brief Intervention (CAMS-BI™).

Support from the CAMS-care team has prepared the Crisis Clinic to successfully anticipate setbacks with patients, without which the patients might have been re-admitted to higher levels of care. Dr. Fischer added, “The CAMS Framework has been powerful not only for our patients but also for our clinicians.” Most notably, it provides a common language and ensures objectivity through tools like the Suicide Status Form (SSF), which supports outpatient treatment decisions.

Clinicians at Children’s Colorado often refer to a quote that Dr. Jobes shares in training materials: “CAMS empowers clinicians by empowering their patients.”

In addition to the CAMS Framework, the Crisis Clinic transforms pediatric mental health care through a multidisciplinary approach. The team consists of Advanced Practice Providers, Behavioral Health Clinicians, Care Coordinators, Psychiatrists, a Psychiatric Pharmacist, and Psychologists, each collaborating to provide holistic services to patients and their families. The roles of a pharmacist for optional medication management and care coordinator for continuity of care ensure a patient-centered, seamless experience during treatment and the post-discharge transition to outpatient or community mental health resources.

Over 6-8 visits, patients work with a dedicated clinician who uses CAMS and complementary modalities to address the drivers of suicidality. The first session spans two hours and entails comprehensive assessment and care planning, with subsequent one-hour sessions focused on progress and adjustment.

Simultaneously, a second clinician supports the family through education, including providing psychoeducation, lethal means counseling, and safety planning. The co-clinician and caregivers use the CAMS Stabilization Support Plan (SSP) to provide ongoing support for the patient’s suicidality.

At the end of each session, the multidisciplinary team huddles amongst themselves to align on progress. They then sync up with the patient and family to plan for the week ahead. Dr. Klott reflected on the process, remarking, “This level of acuity and volume would be overwhelming to navigate alone.”

Between June and December 2024, the Crisis Clinic pilot served 21 patients using the CAMS Framework across 128 total treatment sessions. Patients accessed timely care, with referrals placed before discharge from the emergency department and an average wait time of just 4.6 business days before starting therapy. Overall, the clinical team has observed stabilization in patient-reported ratings related to suicide risk.

According to initial feedback, patients report they learned coping mechanisms and identified contributing drivers of their suicidal thoughts. They valued feeling heard and understood without pressure. They improved communication with family members. They highlighted the importance of efforts to address self-hate and promote self-forgiveness. Dr. Fischer acknowledged how the rapid-access Crisis Clinic is disrupting patterns otherwise seen in the youth mental health crisis, “Without a clinic like this, patients might come back to our Emergency Departments 10 times worse 10 weeks later.”

Beyond offering direct support with the Crisis Clinic and CAMS, Children’s Colorado is spearheading a cultural shift, encouraging open conversations about suicide to reduce the stigma. This includes community screenings and dialogues around the documentary, My Sister Liv, which emphasizes that talking openly about suicidality reduces suicidality rather than increases it. They also share tools such as hotlines and community resources. By addressing a crisis through a suicide-specific lens, they underscore their mission to treat crises not just as moments of distress but as opportunities to empower patients and families toward healing.

Through rapid outpatient services to divert unnecessary hospitalizations, the evidence-based CAMS Framework for patients and their families, and a multidisciplinary care team, Children Colorado’s Crisis Clinic is redefining suicide-specific care for youth in Colorado. While much work remains to reach more youth experiencing mental health crises and close the care gap in Colorado, the Crisis Clinic’s unique, blended model sets a powerful example for other providers focused on reducing youth suicidality to follow.