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1st Year Rotations

Content Overview Of The Cambridge Health Alliance Child Psychiatry Training Program: FIRST YEAR

The first year is divided into five blocks of ten weeks each. In addition, Wednesday and Thursday afternoons are devoted to a longitudinal outpatient experience throughout the year.

Child Assessment Unit (CAU) Block

  • Child Inpatient, Cambridge Hospital, 7th floor (27 hours/week for 10 weeks)

Adolescent Assessment Unit (AAU) Block

  • Adolescent Inpatient, Cahill 3, Cambridge Hospital (27 hours/week for 10 weeks)

PSYCHIATRIC EMERGENCY AND RESIDENTIAL CONSULTATION BLOCK

  • Psychiatric Emergency Services (Cambridge Hospital ED, 8 hours/week for 10 weeks)
  • Psychiatric Transitional Service (Cambridge Hospital Cahill, 1.3 hours/week for 10 weeks)
  • Residential Consultation (Walden Street School, Justice Resource Institute, 6 hours/week for 10 weeks)
  • Early Intervention Observation (The Cambridge Youth Guidance Center, 3 hours/week for 10 weeks)
  • Community Service Agency (Cambridge Youth Guidance Center, 5 hours/week for 10 weeks)

CONSULTATION/LIAISON BLOCK

  • Inpatient pediatrics consultation, Tufts Medical Center (6 hours/week for 10 weeks)
  • Outpatient pediatrics consultation, MIT Pediatric Clinic, Cambridge (4 hours/week for 10 weeks)
  • Outpatient pediatrics consultation, CHA Windsor Street Pediatrics, Cambridge (4 hours/week for 10 weeks)
  • Consultation to State Agencies (Depts. of Mental Health and Children and Families,  various locations (3 hours/week for 10 weeks)

ELECTIVE/SCHOLARLY ACTIVITY BLOCK

  • Independent clinical and scholarly activity time (8 hours/week for 10 weeks)
  • Developmental disorders, office of Karen Levine, PhD (3 hours/week for 10 weeks)
  • Neuropsychological Testing observation (6 hours)
  • Pediatric Neurology, Lurie Center for Autism (4 hours/week for 10 weeks)
  • Preschool Observation and Consultation, Early Years Program and Peabody Terrace Children's Center (3 hours/week for 10 weeks during the Elective Block)
  • Evaluation team (3.5 hours/week for 10 weeks during the Elective Block)

LONGITUDINAL OUTPATIENT EXPERIENCE (Cambridge Hospital, Macht Building)

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

ROTATIONS: FIRST YEAR

INPATIENT

  • Child Assessment Unit (CAU), Cambridge Hospital - 10 weeks
    This clinical experience gives fellows the opportunity to work with multidisciplinary staff, gain experience negotiating with outside systems such as the Department of Children and Families, the Department of Mental Health, and the wrap-around services of the Children’s Behavioral Health Initiative. Fellows develop assessment and treatment skills with oversight and supervision from inpatient psychiatric attendings and visiting faculty. The Rotation Supervisor of the CAU rotation is Dr. Theo Murray.

    Patients range in age from 4 to 13; approximately 30% are from Cambridge and Somerville, while 70% are drawn from a wider geographic area. The patients represent a diverse socioeconomic, ethnic, and cultural mix and present with a wide range of diagnostic problems, including post-traumatic, disruptive, mood, psychotic, and developmental disorders. Clinical focus is on accurate diagnostic assessment, including individual and family evaluations, and broad-based treatment, including psychopharmacology, family work and milieu therapy. With leadership from the Justice Resource Institute, the unit is implementing the Attachment, Self-Regulation, and Competency model, a framework developed for intervention with youth and families who have experienced prolonged trauma. The unit has developed a family-centered model of care and also hosts the Sibling Support Project. This project is a sibling support group designed to increase the resiliency of typically developing siblings and decrease the trauma associated with the psychiatric hospitalization of a brother or sister.

    Educational activities include: Weekly interview and case formulations conference with outside faculty; weekly family therapy case conference; weekly clinical supervision from outside faculty; weekly supervision with an onsite supervisor; co-leading a group to promote self-regulation; and informal supervision from psychiatric and psychology staff.

    Teaching opportunities include supervising medical students, adult psychiatry and pediatric residents. Fellows also are expected to present and implement evidence-based treatment plans in team meetings.
  • Adolescent Assessment Unit (AAU), Cahill 3, Cambridge Hospital - 10 weeks
    The AAU rotation provides a rich clinical experience with adolescents and their families involving close work with multidisciplinary staff in a team format, both as primary clinician on cases and as the medication consultant. Fellows gain experience negotiating with outside systems and presenting evaluations in teams and to outside providers in systems meetings. The Rotation Supervisor of the AAU rotation is the unit's medical director, Dr. Gloria Carrera.

    This unit has 14 inpatient beds. The population ranges in age from 12 to 19, with approximately 50% of patients from the local Cambridge/Somerville area and 50% from the greater Massachusetts and New England regions. Like the CAU, the patients represent a diverse socioeconomic, ethnic and cultural mix. The AAU serves a wide range of adolescents with diagnoses including: PTSD, mood disorders, psychotic disorders, substance abuse, ADHD, and other disruptive disorders. Systems work involves school and program (residential) consultation.

    Faculty on both inpatient units include child and adolescent psychiatrists, social workers, psychologists, nurse managers, staff nurses, and milieu counselors. Faculty members are experienced in assessment, psychotherapy, play therapy, behavior modification, psychopharmacology, substance abuse, and family therapy.

    Educational activities include: Weekly interview and case formulations conference with outside faculty; biweekly addiction case conference; clinical and psychopharmacology supervision from faculty; weekly supervision with an onsite supervisor; and informal supervision as needed. Fellows also co-lead a supervised dialectical behavior therapy (DBT) group. Teaching opportunities include: Supervising medical students, general psychiatry residents, and pediatric residents. Research opportunities include a trainee-initiated survey of internet and technology habits among adolescent inpatients and their relationship to mental health disorder.

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PSYCHIATRIC EMERGENCY AND RESIDENTIAL CONSULTATION BLOCK

The Cambridge Hospital's Psychiatric Emergency Service (PES) is a consultation service based in the medical emergency room. It is the entry point for all acute psychiatric services, and also provides evaluation and urgent treatment to children, adolescents, adults, and families. Patients seen by the PES team are children and adolescents aged 18 and under, though adolescents outnumber latency age children, with an equal number of male and female patients. The Rotation Supervisor of the PES experience is Dr. Theo Murray, who provides supervision for each case seen and in weekly 1:1 and staff meetings.

Emergency assessments are directed at determining patient needs for acute stabilization and appropriate/least restrictive level of care. Fellows spend 8 hours a week for 10 weeks on this rotation.

The Cambridge Hospital's Psychiatry Transition Service (PTS) is a consultation service based in Cahill 1, next door to the medical emergency room. It serves youth who were recently seen by the PES team in the ER and are in need of urgent follow-up as a bridge to outpatient care or as a means for supportive re-evaluation following the acute presentation. As with the PES, patients seen by the PTS youth aged 18 and under. The Rotation Supervisor of the PTS experience is Dr. Amy Mayhew, who provides supervision for each case seen and in weekly 1:1 and staff meetings.

Residential Consultation Rotation: The Walden Street School is a therapeutic residential program of the Justice Resource Institute for young women offering a specialized trauma-informed approach, known as Attachment, Self-Regulation, and Competency (ARC). Fellows spend one day per week under the supervision of Dr. Kerry-Ann Williams participating in treatment team, groups, and milieu treatment of students at the residential school.

The Community Service Agency (CSA) rotation at the Cambridge Youth Guidance Center
This rotation introduces fellows to wrap-around services offered in the setting of a community mental health center. These services are offered through the Massachusetts’ Child Behavioral Health Initiative (CBHI), an innovative statewide reform of public child mental health care emphasizing strengths-based, wrap-around community supports. Fellows participate in team evaluations of children and families, join staff on home visits, and develop a comprehensive treatment plan. Becoming more familiar with community-based resources, working within a multidisciplinary treatment team, and acting as a psychiatric consultant to CBHI service providers are also critical goals of this rotation. The rotation supervisor is Kimberly Martin-Conley, LICSW.

Early Intervention Observation
Fellows spend one morning per week with the Early Intervention program at the Cambridge Youth Guidance Center. This experience involves observation of Early Intervention groups and of home-based assessments under the supervision of Kathy Kelts, LICSW. Fellows learn how preventive strategies are practiced in a state-supported program. Fellows also deepen their theoretical and practical understanding of normal development at this stage of life, and learn to distinguish it from clinical pathology.

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CONSULTATION/LIAISON

Inpatient Consultation-Liaison
The Floating Hospital for Children at Tufts Medical Center in downtown Boston is a 100-bed pediatric tertiary care hospital within Tufts Medical Center. CHA Fellows rotate at the hospital 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. In addition, fellows participate in more specialized inpatient consultation experiences on both the Pediatric Intensive Care Unit and the Bone Marrow Transplant Unit at the Floating Hospital. Fellows spend approximately 16 hours per week over a 10-week period at Tufts performing clinical consultations, presenting cases, attending a teaching conference, and receiving supervision. The rotation supervisor and C/L director is currently Dr. John Sargent. Fellows will also teach consultation psychiatry to Tufts Medical Students. All fellows also have weekly supervision with Dr. Sargent.

Outpatient Consultation-Liaison
The Integrated Care Consultation-Liaison rotation at CHA's Windsor Street Pediatric Clinic gives first-year fellows the opportunity to work in an integrated care model for 4 hours a week for 10 weeks. Child psychiatrists Katherine Grimes, MD, and Cecil Webster, MD, in collaboration with pediatrician Greg Hagan, MD, (Chief of Pediatrics) work together with the rotating fellow to identify patients requiring psychiatric consultation. Pediatric residents from the Massachusetts General Hospital also participate int he experience. Some consultations are scheduled ahead of time; others are ad hoc in real time, based on Dr. Hagan’s assessment during a sick visit or well-child check. As health care nationally moves towards an Accountable Care Model of delivery, this innovative rotation is designed to prepare fellows for the future of integrated pediatric health care. Fellows also work with pediatric residents to learn outpatient pediatrics and teach on child psychiatry topics. Outcomes are being assessed for this clinic and there is an opportunity to be involved in healthcare delivery research with Drs. Grimes and Hagan.

The Outpatient Pediatrics Consultation/Liaison rotation at the Massachusetts Institute of Technology (MIT) Health Services provides pediatric care to the children of students, faculty and general employees at the university. Fellows spend one afternoon (4 hours) a week for 10 weeks seeing children and families referred by their MIT pediatricians for a variety of psychiatric concerns. They then discuss the case in supervision with Dr. Deborah Kulick, the rotation supervisor. Fellows learn about the consultative frame in general and consultation to pediatricians in particular. There is also the opportunity to follow one MIT case for outpatient mental health treatment at the Cambridge Hospital clinic.

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 are supervised by Dr. Nandini Talwar, a DMH child and adolescent psychiatrist who has extensive experience working with state and community agencies. During the consultation, the trainees participate in discussions of complicated cases presented by DCF case managers and supervisors. 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 monthly meetings with the group of senior DMH child psychiatrists 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. In addition, the fellows will participate in a once a month interagency meeting with representation from DMH, DCF, DDS (Department of Developmental Services), DYS (Department of Youth Services), Department of Education and the Department of Public Health. This meeting provides updates about services and changes in each of the participating state agencies as well as a forum for consultation to high-risk and underserved families who are in need of services from more than one agency.

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ELECTIVE/SCHOLARLY ACTIVITY

Independent clinical/scholarly activity
This rotation provides 8 hours per week for 10 weeks of elective time so that fellows can pursue scholarly activities or quality improvement in their own particular area(s) of interest, meet potential mentors, and prepare for their clinical scholarship and elective time in the second year.

Developmental Disorders/Intellectual Disability
Fellows spend approximately 2.5 hours a week for 10 weeks during the Elective rotation observing evaluations at the office of Dr. Karen Levine, an award-winning developmental psychologist, in Lexington. The experience gives fellows exposure to young children with a range of developmental disorders including Autism Spectrum Disorders, with or without intellectual disability, and to various systems of care for these children and adolescents. Uses of play in assessment and treatment of this population are emphasized.

Preschool Observation and Consultation
The Early Years program is a consultation service provided by the Cambridge Department of Health to any Cambridge-based preschool or daycare. Early Years consultants (three clinical social workers) assess children in their classroom setting and provide feedback and recommendations to teachers and staff. Fellows join the Early Years team meeting every second week support the consultation process and have opportunities to participate in educational activities offered to parents and preschool staff (“Ask the Doc” evenings). The rotation supervisor is Dr. Malak Rafla.

The Peabody Terrace Children’s Center is a Harvard-affiliated preschool for health children ranging in age from 2 months to 5 years who are primarily children of Harvard University faculty, students and staff. The children are divided into several age-based “classes,”, each of which is designed to meet the developmental needs of its assigned group. Supervision is provided by Susannah Sherry, MD.

Fellows spend 2.5 hours every second week for 10 weeks on this rotation. The experience allows the fellows to observe preschool children who are, for the most part, on track developmentally in a group setting while providing consultation to pre-school staff on those children who present with developmental, social, emotional, communication, or other potential concerns. Fellows spend 1.5 hours weekly in observation of one of two preschool toddler or infant classrooms and consult with teachers and the center director as needed.

During this rotation, the fellow functions as an observer and a consultant without any direct clinical responsibility. In addition, fellows may be asked to provide an in-service teaching session to staff during the rotation.

Pediatric Neurology
The fellows spend one morning a week for 10 weeks at the Lurie Center for Autism in Lexington, MA. They learn to take a pediatric and neurological history with a particular emphasis on birth and early development. School histories are also detailed. Areas addressed include the subtleties of abnormalities in processing and modulating sensory input (auditory, visual, and tactile), difficulties in perception and/or medical conditions that are mistaken for psychiatric or behavioral disorders. Fellows review and perform a neurological evaluation, including cranial nerves, motor (fine motor, gross motor, and balance), and sensory and mental status assessments. Fellows are taught and expected to dictate a complete report on the patients they have evaluated which are then reviewed by the supervising neurologist Dr. Ann Neumeyer.

Neuropsychological Observation
During the neurology rotation in the Elective block, fellows will spend six hours observing neuropsychological testing of children with Laura Gaugh, PsyD. Fellows observe in-depth evaluations of cognition, emotions, language, and development with youth and participate in feedback sessions with families.

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LONGITUDINAL OUTPATIENT EXPERIENCE – FIRST YEAR

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, approximately 60% of whom are male and 40% of whom are female, with a relatively even split between children and adolescents. These children are most commonly diagnosed with disorders of adjustment or trauma, depression, anxiety, and disruptive behaviors (ADHD, ODD). School behavioral problems, learning disabilities, physical or sexual abuse, and family disorganization are frequently part of the clinical picture. The cultural and ethnic mix of patients includes Portuguese, Latino, and Haitian. Treatment of such families is facilitated by CHA’s excellent interpreter services.

The Child Ambulatory Service provides approximately ten thousand visits per year. Clinical services available at the Macht building on our main campus include a psychotherapy clinic, a psycho-pharmacology clinic, a neuropsychological and developmental testing program, a clinic for deaf and hard-of-hearing children, a family therapy clinic, and a group therapy program.

In addition to the Macht outpatient service, children and adolescents are seen by our staff at local school-based health centers, at CHA community pediatrics and family medicine clinics in an integrated primary care model, and at regional residential treatment and educational facilities. CHA providers also consult to the Cambridge Police Department (Safety Net Program), to Cambridge preschool and daycare centers (Early Years Program), and to primary care providers in the Cambridge region (Massachusetts Child Psychiatry Access Project).

Team Evaluation Clinic
First-year fellows spend 10 weeks during their Elective rotation on a weekly 3.5- hour Evaluation Team. The team is multidisciplinary (psychiatry, psychology, family medicine, pediatrics, nursing, medical students) and provides in-depth initial assessments of families over two sessions. This setting provides an excellent opportunity for fellows to observe senior faculty interview patients, to receive direct feedback on their own interviewing skills, to practice in-depth biopsychosocial formulation skills (both written and in presentation to the team), to learn local resources and systems available for families, and to work together in a team setting to think through diagnostic formulations and treatment plans.

Outpatient Psychotherapy Clinic
Fellows spend their time learning and providing psychotherapy and psycho-pharmacology 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 case management. Many cases will involve combined treatment (both psychotherapy and medications).

First year fellows have at least three therapy hours a week, primarily for psychotherapy, but also for evaluations, family work, and case management. First-year fellows receive a minimum of 2 hours of weekly outpatient supervision.

Precepted Psycho-pharmacology Clinic
The 3-hour psycho-pharmacology clinic is devoted to the medication management of patients in a split treatment model. It is precepted by an attending child psychiatrist who is available to help fellows with diagnostic interviewing and treatment planning, to answer any questions the trainee may have, and to guide fellows’ self-directed learning about evidence-based treatments in clinical practice. Preceptors provide feedback on interviewing skills and documentation. Current preceptors are Malak Rafla, MD; Susan Walker, MD; and Nicholas Carson, MD.

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