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INPATIENT

Child Assessment Unit (CAU)

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

Adoelscent Assessment Unit (AAU)

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

OUTPATIENT (Cambridge Campus, Macht Building)

• Evaluation team
  (3.5 hours/week for 26 weeks)
  
• Psychotherapy
  (individual, group and family, 3 hours/week for 52 weeks)
  
• Precepted psychopharmacology clinic
  (3 hours/week for 52 weeks)

PSYCHIATRIC EMERGENCY SERVICES (PES)

• Emergency room, Cambridge Hospital Campus
  (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, Tufts Medical Center (19 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 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)

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 are offered opportunities to 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, including post-traumatic, 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 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.

Educational activities include: Weekly interview and case formulations conference with outside faculty; pediatric rounds 1 hour every week with a consulting pediatrician; biweekly family therapy case conference; biweekly conference on Collaborative Problem Solving; weekly clinical supervision from outside faculty; weekly supervision with an onsite supervisor; and informal supervision as needed.

Teaching opportunities include supervising medical students, adult psychiatry and pediatric residents.

Adolescent Assessment Unit (AAU), Cahill 3, Cambridge Campus - 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. The population ranges in age from 12 to 19, 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. We have access to many kinds of interpreters including ASL for deaf patients. Like the CAU, this unit serves a wide range of adolescents with diagnoses including, but not limited to: PTSD, ADHD, mood disorders, psychotic disorders, substance abuse, and 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.

Teaching opportunities include: Supervising medical students, general psychiatry residents, and pediatric residents.

II. OUTPATIENT

The CHA 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. Half the children are 12 or under, half are 13 or older. These children are most commonly diagnosed with conduct disorders, depression, Post-Traumatic Stress Disorder, Oppositional Defiant Disorder, Attention Deficit Hyperactivity Disorder, and adjustment disorders. 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 Latino, Haitian, and Portuguese.

The Child Ambulatory Service handles approximately 10,466 visits per year. Among the components of the service are a psychotherapy clinic, a psychopharmacology clinic, and a small clinic for deaf and hard-of-hearing children.

In addition to the Macht outpatient service, children and adolescents are seen by our staff at local schools and in neighborhood health centers. Fellows have an opportunity to view this experience first-hand during the Community Service Agency rotation during the PES block.

The educational experience on the outpatient service includes:

• Team Evaluation Clinic. First-year fellows spend 10 weeks during their Elective rotation and second-year fellows spend 26 weeks attending a weekly 3- hour Evaluation Team meeting. The team is multidisciplinary and provides initial assessments to patients new to the clinic. This setting provides an opportunity for fellows to watch senior faculty interview patients; to be observed interviewing patients; and to work together in a team setting to think through diagnostic formulations and treatment plans.

• Outpatient Clinic. 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.

First year fellows carry 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 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 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 Sandra DeJong, MD, Michele Deneys, MD, and Susan Walker, MD.

III. PSYCHIATRIC EMERGENCY SERVICE

The CHA'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. Adolescents outnumber latency age children, with an equal number of male and female patients.

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 other experienced clinicians in Emergency Services. Faculty supervision is provided for each case seen and in weekly 1:1 and staff meetings with the supervisor.

Christine Wittmann, MD, PES Assistant Director for Child and Adolescent Services, is the rotation supervisor.

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. Rotation Supervisor is Carol Murphy, LICSW.

• 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.

IV. CONSULTATION/LIAISON

• Inpatient C/L. 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 have the opportunity to 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. Fellows will also have opportunity to teach Tufts Medical Students. 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 and staff. The children are divided into seven classrooms, each of which is designed to meet the developmental needs of its assigned group. This 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 groups. In addition, it provides an opportunity to act as a consultant in a preschool setting and to consider the issues involved in acting as a consultant. Fellows spend one hour weekly in observation of one of two preschool toddler or infant classrooms and one hour weekly consulting with teachers and the center director.

  During this rotation, the fellow functions as a consultant without any direct clinical responsibility. In addition, 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, a child and adolescent psychiatrist who has extensive experience working with state and community agencies. During the consultation, the trainees will hear about 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 a once a month meeting with the group of Massachusetts DMH child and adolescent 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, formerly known as Department of Mental Retardation), DYS (Department of Youth Services), Department of Education and the Department of Public Health. This meeting will serve to provide 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.

V. ELECTIVE/SCHOLARLY ACTIVITY

• Independent clinical/scholarly activity. This rotation provides 10-15 hours per week for 10 weeks of elective 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. The rotation includes doing assessments, working with individual patients and participating in treatment groups. Marc Libman, MD, is the rotation supervisor.

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. Marc Libman, MD, is the rotation supervisor.

• 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, a developmental neuropsychologist, 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 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.