ROTATIONS

Content Overview Of The Cambridge Health Alliance Child And
Adolescent Psychiatry Training Program:

FIRST YEAR

INPATIENT
Child Assessment Unit (CAU)

• Child Inpatient, Cambridge Hospital (30 hours/week for 10 weeks)

Adolescent Assessment Unit (AAU)

• Adolescent Inpatient, Cahill 3, Cambridge Hospital (30 hours/week for 10 weeks)

PSYCHIATRIC EMERGENCY SERVICES (PES)

• Emergency room, (Cambridge Hospital, (19 hours/week for 10 weeks)
• Community Service Agency (Cambridge Youth Guidance, 5 hours/week for 10 weeks)
• Neuropsychological testing observation (Cambridge Hospital, 3 hours/week for 10 weeks)

CONSULTATION/LIAISON

• Inpatient consultation, Floating Hospital for Children/Tufts Medical Center, Boston (16 hours/week for 10 weeks)
• Outpatient consultation, MIT Pediatric Clinic, Cambridge (4 hours/week for 10 weeks)
• Preschool consultation, Soldier’s Field Park Children’s Center, Cambridge (2.5 hours/week for 10 weeks during the Elective Block)  
• Consultation to State Agencies (Depts. of Mental Health and Children and Families,  various locations (3 hours/week for 10 weeks)

ELECTIVE AND SCHOLARLY ACTIVITY

• Independent clinical and scholarly activity time (site and hours vary, 8 weeks)
• Developmental disorders, office of Karen Levine, PhD (2.5 hours/week for 10 weeks)
• Preschool Children:  Clinical Issues and Normal Development (1.5 hours/week for 8 weeks)
• Eating disorders, Cambridge Eating Disorder Center (11.5 hours/week for 2 weeks)
• Evaluation team (3.5 hours/week for 10 weeks)

OUTPATIENT (Cambridge Hospital Macht Building)

• Psychotherapy (individual, group and family, 3 hours/week for 52 weeks)
• Precepted psychopharmacology clinic (2.5 hours/week for 52 weeks)

ROTATIONS: FIRST YEAR

I. INPATIENT

• Child Assessment Unit (CAU), Cambridge Hospital - 10 weeks
  This clinical experience gives fellows a chance to work with multidisciplinary staff, gain experience negotiating outside systems such as the Department of Children and Families, Department of Mental Health, and the newly-developed services under the umbrella of the Children’s Behavioral Health Initiative.  Fellows work in multidisciplinary teams and develop assessment and treatment skills with oversight and supervision, both in a “split-treatment” model and as the primary provider. The Cambridge Hospital CAU opened in 1989 and houses 13 acute inpatient beds. Patients range in age from 2 to 13; approximately 30% are from Cambridge and Somerville, while 70% are drawn from a wider geographic area. The patients represent a diverse ethnic and cultural mix and present with a wide range of diagnostic problems.  The unit has been involved in a major research project with Ross Greene, PhD, using his Collaborative Problem Solving approach to manage aggressive behavior and eliminate the use of restraint and seclusion. The unit has also has developed a family-centered model of care.
  
  In addition to learning inpatient care, fellows have seminars in family systems consultation and interviewing and case formulations. Teaching opportunities include supervising medical students, adult psychiatry and pediatric residents.

• Adolescent Assessment Unit (AAU), Cahill 3, Cambridge Hospital - 10 weeks
  The rotation provides a rich and diverse clinical experience and a chance to work with multidisciplinary staff in a team format, both as primary provider on the case and as the medication consultant. Fellows gain experience negotiating outside systems and presenting evaluations in teams and to outside providers in systems meetings.
  
  This unit has 14 inpatient beds. Patients range from 12 to 19 years, with approximately 50% of patients from the local Cambridge/Somerville area and 50% from further away. The patients represent a diverse ethnic and cultural mix. Educational activities include interview and case formulations conference; weekly family therapy case conference; and a substance abuse and dual diagnosis seminar. Teaching opportunities include: Supervising medical students, adult psychiatrists and pediatric residents.
  
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II. OUTPATIENT

The Cambridge Hospital Child and Adolescent Outpatient Service is located at the Macht Building and provides evaluation and treatment to children from ages 3 to 18 The clinic handles approximately 8,500 visits per year.. The cultural and ethnic mix of patients includes Latino, Haitian, and Portuguese and deaf and hard-of-hearing children.

In addition to Macht, children and adolescents are seen by our staff at local schools and in neighborhood health centers. 

• Evaluation Team Clinic
  First-year fellows spend 10 weeks during their PES and second-year fellows spend 13 weeks participating in a 3-hour intake process as part of the multidisciplinary Evaluation Team. First-year fellows learn the skills of conducting an outpatient evaluation of children, adolescents and families through faculty observation and feedback either in-person or through a two-way mirror during the first year. Videotaped parental and family consultation are also provided.

• Outpatient Clinic
  Fellows learn how to provide psychotherapy and  psychopharmacology to diverse populations. The essential experience includes family work, individual psychodynamic psychotherapy, supportive and cognitive/behavioral interventions, consultation with community agencies and schools, and general clinical management.
  
  First year fellows carry three therapy hours a week primarily for psychotherapy but also for evaluations, family work, and ongoing management. First-year fellows receive a minimum of 2 hours of weekly outpatient supervision.

• Precepted Psychopharmacology Clinic
  The 2.5 -hour psychopharmacology clinic is devoted to the medication management of patients in a split treatment model.  It is precepted by an attending child psychiatrist who helps with diagnostic interviewing and treatment planning, answers any questions the trainee may have, and guides fellows’ self-directed learning about evidence-based treatments in clinical practice. Preceptors provide feedback on interviewing skills and documentation. Current preceptors are Sandra DeJong, MD, Fida Hassan, MD, and Susan Walker, MD.
  
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III. PSYCHIATRIC EMERGENCY SERVICE

The Cambridge Hospital’s Psychiatric Emergency Service is the entry point for all acute psychiatric services, and also provides evaluation, urgent treatment, and community outreach to children, adolescents, adults, and families. Patients are children and adolescents aged 18 and under. Evaluations/assessments are directed at determining patient needs for acute stabilization and appropriate/least restrictive level of care. Fellows spend 19 hours a week for 10 weeks on this rotation. Cases in this rotation are supervised by a child and adolescent attending psychiatrist who interacts with the Medical Director and Staff Psychologists, social workers and other experienced clinicians in Emergency Services. Faculty supervision is available for each case seen.


The Community Service Agency (CSA) rotation at The Cambridge Youth Guidance Center introduces fellows to working in a community mental health center. The CSA rotation aims to introduce residents to the Massachusetts’ Child Behavioral Health Initiative (CBHI), a statewide reform of public child mental health care.  Residents participate in evaluating children and families, and developing a comprehensive treatment plan using the concept of wraparound services.  Becoming more familiar with community-based resources, working within a multidisciplinary treatment team, and acting as a psychiatric consultant in a community setting are also critical goals of this rotation.

• Neuropsychology
  During the PES block, fellows spend one morning a week learning about neuropsychological testing of children with Laura Gaugh, PhD.  They observe her perform neuropsychological testing with children and adolescents and participate in the feedback sessions with families.
  
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IV. CONSULTATION/LIAISON

• Inpatient C/L
  The Floating Hospital for Children in downtown Boston is a 100-bed, pediatric, tertiary-care hospital within Tufts Medical Center. CHA Fellows rotate at the hospital with Tufts Child and Adolescent Psychiatry Fellows performing inpatient consultations on children and adolescents who have a wide range of concerns including psychological difficulties associated with pediatric illness, unexplained somatic symptoms, child abuse and neglect, pain management and problems managing chronic illness. All fellows have individual, once weekly supervision with John Sargent, MD, Chief of Child and Adolescent Psychiatry at Tufts, and/or the consultation-liaison attending.

• Outpatient C/L
  The Outpatient Pediatric Clinic at the Massachusetts Institute of Technology (MIT) Health Services provides pediatric care to the children of students, faculty and general employees at the Institute. Fellows spend one afternoon (4 hours) a week for 10 weeks seeing children and families referred by their MIT pediatrician for a variety of psychiatric concerns. Fellows have an opportunity to learn about the consultative frame in general and consultation to pediatricians in particular, and to pick up one case for outpatient follow-up at their Cambridge Hospital clinic. The rotation supervisor is Dr. Sherry Bauman.

• Preschool Consultation
  The Soldiers Field Park Children’s Center in Cambridge is attended by 73 healthy children ranging in age from 2 months to 5 years. They are primarily children of Harvard University faculty, staff and graduate students. TThis consultation is supervised by a child psychiatrist, Jeanne Heiple, MD, PhD.
  
  Fellows spend 2 hours a week for 10 weeks on this rotation. The experience allows the fellows to observe "normal" preschool children in group, act as a consultant in a preschool setting, and consider the issues involved in acting as a consultant. During this rotation, the fellow has no direct clinical responsibility.  Fellows provide a 1-hour in-service teaching session to staff at some point during the rotation.

• Systems Consultation to State Agencies
  The MA Department of Mental Health (DMH) is a state agency that sets the standards for the operation of mental health facilities and community residential programs and provides clinical, rehabilitative, and supportive services for adults and children with serious mental illness or serious emotional disturbances. The Department for Children and Families (DCF) is the child welfare agency in Massachusetts.  During this 10-week rotation, first year child psychiatry Fellows will spend 3 hours a week accompanying the faculty during weekly consultations to DMH and DCF at various sites within our catchment area.
  
  Fellows will be supervised by Dr. Nandini Talwar. During the consultation, case managers present complex cases, and trainees learn about services and opportunities provided by state agencies; criteria for eligibility for services from state agencies; the process of investigation and assessment for allegations of abuse and neglect; as well as the various dilemmas and limitations faced by agencies when working with families and clients. Fellows will also participate in meetings with DMH psychiatrists and other state clinical workers to discuss a variety of topics including high-risk and complicated cases, changes and trends in the mental health system in MA, and other important issues related to public mental health care for children. 
  
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ELECTIVE/SCHOLARLY ACTIVITY

• Independent clinical/scholarly activity
  This rotation provides 10-15 hours per week for 10 weeks of undesignated time so that fellows can pursue clinical or scholarly activities in their own particular area of interest(s).

• Eating Disorders
  The Cambridge Eating Disorders Clinic (CEDC) is an intensive outpatient and residential treatment center for adolescents with a variety of eating disorders. Treatment consists primarily of group therapy. Fellows spend 11.5 hours over 2 weeks working on an adolescent partial hospitalization unit as well as an adolescent residential program. The rotation includes doing assessments, working with individual patients and participating in groups.

• Developmental Disorders/Mental Retardation
  Fellows spend approximately 2.5 hours a week for 10 weeks during the Elective rotation observing evaluations at the office of Dr. Karen Levine, a developmental neuropsychologist, in Lexington. The experience gives fellows exposure to a range of developmental disorders, with or without mental retardation, and to various systems of care for these children and adolescents.

• Preschool Children:  Clinical Issues and Normal Development
  Fellows spend one morning a week with child psychiatrist Margaret “Polly” Gean, MD, doing consultations with preschoolers and their families.  Fellows deepen their understanding of normal development at this stage of life, and learn to distinguish it from clinical pathology.
  
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