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.

I. Child Assessment Unit (CAU)

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

II. Adolescent Assessment Unit (AAU)

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

III. Psychiatric Emergency and Transition Service (PETS)

  • 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)
  • Evaluation Team (3.5 hours/week for 10 weeks)
  • Early Intervention Observation (The Guidance Center, 3 hours/week for 6 weeks)
  • Community Service Agency (The Guidance Center, 5 hours/week for 10 weeks)

IV. Consultation/Liaison

  • Inpatient Pediatrics Consultation, Tufts Medical Center (16 hours/week for 10 weeks)
  • Outpatient Pediatrics Consultation, MIT Pediatric Clinic, 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)
  • Preschool Observation and Consultation, Peabody Terrace Children’s Center (2.5 hours/week for 5 weeks)
  • Neuropsychological Testing Review (1.25 hours/week for 5 weeks)

V. Walden Residential, Elective, Neurology, Developmental Disorders, Integrated-Care (WENDI) Block

  • Residential Consultation (Walden Street School, Justice Resource Institute, 6 hours/week for 10 weeks)
  • Independent Clinical and Scholarly Activity Time (8 hours/week for 10 weeks)
  • Pediatric Neurology, Lurie Center for Autism (4 hours/week for 10 weeks)
  • Developmental Disorders, office of Karen Levine, PhD (2.5 hours/week for 10 weeks)
  • Neuropsychological Testing Observation (6 hours during the 10 weeks)
  • Outpatient Pediatrics Primary Care Mental Health Integration Service, CHA Cambridge Pediatrics, Cambridge (4 hours/week for 10 weeks)

VI. Longitudinal Outpatient Experience (Cambridge Hospital, Macht Building)

  • Psychotherapy (3 hours/week for 52 weeks)
  • Precepted Psychopharmacology Clinic (3 hours/week for 52 weeks)

Rotations: First Year

I. Child Assessment Unit (CAU), Cambridge Hospital, 7th Floor - 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. Fida Hassan.

Patients range in age from 2 to 13; approximately 30 percent are from Cambridge and Somerville, while 70 percent 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. The unit has received recognition for its development of strategies to reduce the use of restraint and seclusion. The unit has also developed a family-centered model of care.

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 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.

II. Adolescent Assessment Unit

(AAU), Cambridge Hospital, Cahill 3 - 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 the 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 Dr. Fred Crow.

This unit has 14 inpatient beds. The population ranges in age from 12 to 19, with approximately 50 percent of patients from the local Cambridge/Somerville area and 50 percent from the greater Massachusetts and New England regions. Like the CAU, the patients represent a diverse socioeconomic, ethnic and cultural mix. CHA provides access to an award-winning interpreter service including ASL for deaf and hard-of-hearing patients. 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, weekly family therapy case conference; weekly clinical supervision from outside faculty, weekly supervision with an onsite supervisor and informal supervision as needed. Teaching opportunities include supervising medical students, general psychiatry residents and pediatric residents.

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III. Psychiatric Emergency and Transition Service (PETS)

  • The Cambridge Hospital’s Psychiatric Emergency Service (PES)
    The 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. Lee Robinson, who provides weekly 1:1 supervision. 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)
    The 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 in the PTS are youth aged 18 and under. The Rotation Supervisor of the PTS experience is Dr. Amy Mayhew, who provides supervision for each case seen in weekly 1:1 supervision and staff meetings.
  • Team Evaluation Clinic
    First-year fellows spend 10 weeks during their PETS rotation on a weekly 3.5-hour Evaluation Team. The team is multidisciplinary (psychiatry, psychology, social work, 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. The rotation supervisor is Nicholas Carson, MD.
  • The Community Service Agency (CSA) rotation at The Guidance Center
    This rotation introduces fellows to wraparound 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 the 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 Allison Clark, LICSW.
  • Early Intervention Observation
    Fellows spend one morning per week with the Early Intervention program at The Guidance Center. This experience involves observation of Early Intervention groups and of home-based assessments under the supervision of Kathy Kelts, LCSW. 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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IV. 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 with 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 Dr. John Sargent, Chief of Child and Adolescent Psychiatry at Tufts. Fellows will also teach consultation psychiatry to Tufts Medical Students and have weekly supervision with Dr. Sargent.
  • Outpatient Consultation-Liaison
    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.
  • 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.
  • Preschool Observation and Consultation
    The Peabody Terrace Children’s Center is a Harvard-affiliated preschool for healthy 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.
  • Neuro/Psychological Testing Review
    Fellows will spend 1.25 hours every second week for 10 weeks reviewing psychological and neuropsychological testing results, with our clinical psychologist, and neurodevelopmental testing expert, Laura Gaugh, PsyD. Throughout the rotation, fellows will review testing results offered by Dr. Gaugh, or from the fellow’s outpatient caseload, with the goal of familiarizing the fellows with the types of tests they may encounter, and how best to interpret the testing results in the context of the greater cultural and linguistic clinical picture. Types of testing may include tests of cognitive functioning, academic performance, adaptive functioning, language, executive functioning, visuospatial and visuomotor functioning, learning and memory and social communication.

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V. Walden Residential, Elective, Neurology, Developmental Disorders, Integrated-Care (WENDI)

  • 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.
  • Independent Clinical and Time/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.
  • 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.
  • Developmental Disorders
    Fellows spend approximately 2.5 hours a week for 10 weeks 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.
  • Neuropsychological Observation
    During the neurology rotation, 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.
  • Outpatien Pediatrics Primary Care Mental Health Integrated Service
    The Pediatric Primary Care - Mental Health Integration (PCMHI) Service at CHA Cambridge Pediatrics Clinic gives first-year fellows the opportunity to work alongside an attending child psychiatrist (Lee Robinson, MD) in an integrated care model for 4 hours a week for 10 weeks. Fellows will learn how to consult to, and collaborate with, pediatricians and primary care staff to address pediatric mental health needs in the primary care setting. Fellows will learn about pediatric primary care culture, workflows and staffing, and what role pediatricians play in the mental health care for many of our patients. Fellows will learn how the child psychiatrist on a PCMHI team can provide consultation to pediatricians through indirect case consultations, direct “face-to-face” consultations and brief, urgent evaluations. Fellows will learn how to perform brief psychiatric interventions (both somatic and psychotherapeutic) for children and families in the primary care setting, and how to co-manage mental health care with pediatricians. 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.

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VI. 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 psychopharmacology 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 both co-located and integrated primary care models, and at regional residential treatment and educational facilities. CHA providers also consult to the Cambridge Police Department (Safety Net Program) and to Cambridge preschool and daycare centers (Early Years Program).

  • Psychotherapy
    Fellows spend their time learning and providing 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 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 Psychopharmacology Clinic
    The 3-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 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, Sandra DeJong, MD, MSc and Lee Robinson, MD.

 

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