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ROTATIONS: FIRST YEAR
I. INPATIENT
Child Assessment Unit at the Cambridge Hospital campus (CAU)
10 weeks
This clinical experience gives fellows a chance to work with multidisciplinary
staff, gain experience negotiating outside systems such as the Department
of Social Services, and develop assessment and treatment skills
with oversight and supervision, both in a "split-treatment"
model and as the primary provider. The 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, Ph.D., 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: Biweekly interview and case formulations
conference; clinical and psychopharmacology supervision from outside
faculty; weekly supervision with an onsite supervisor; and informal
supervision as needed.
Adolescent Assessment Unit at the Somerville Hospital campus
(AAU) (10 weeks)
The rotation provides a rich and diverse clinical experience and
a chance to work with multidisciplinary staff in a team format.
Fellows gain experience negotiating outside systems and presenting
evaluations in teams and to outside providers in systems meetings.
This unit has 18 inpatient beds. The population ranges in age from
12 to 19, with approximately 50% of patients from the local Cambridge/Somerville,
MA area and 50% from further away. The patients represent a diverse
ethnic and cultural mix. We have access to many kinds of translators
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: Interview and case formulation
conference weekly; clinical supervision from outside faculty; weekly
individual supervision with an attending psychiatrist; and informal
daily supervision as needed.
II. OUTPATIENT ROTATIONS
The CHA Child and Adolescent Ambulatory Service provides evaluation
and treatment to children from ages 3 to 18, 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 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 8,500 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, services are provided
within both school and neighborhood health centers.
The educational experience includes:
Team Evaluation Clinic
First-year fellows spend 10 weeks and second-year fellows spend
26 weeks attending a weekly 3½ 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 general psychopharmacology to diverse populations. The essential
experience includes family work, individual psychodynamic psychotherapy,
supportive and cognitive/behavioral interventions, consultation
with other social service agencies and with schools, and general
clinical case management.
First year fellows carry three therapy hours, 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 precepted by an attending
child psychiatrist who is available to help 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.
III. PSYCHIATRIC EMERGENCY SERVICE
The CHA Psychiatric Emergency Service at the Cambridge Hospital
campus 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 13 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 Cambridge Guidance Center is a community mental health
center where fellows learn about wrap-around services. During this
rotation fellows spend 5 hours a week during the 10 weeks at Cambridge
Youth Guidance working with center director Charlene Zuffante, LICSW,
and her team putting together wrap-around services for high-risk
patients and families.
IV. CONSULTATION/LIAISON
Inpatient C/L
The Shriners Hospital, Boston, is an international referral
center for burn injuries and a major center of research on burn
injuries in children and adolescents. The patient population commonly
includes neglected or abused children, and children of parents with
PTSD, depression, or alcoholism. Many children and families have
survived near-death experiences due to burns or have grieved the
loss of a loved one. Children from all over Latin America, Asia,
Europe, the U.S., and Canada travel to this center for treatment.
The center provides opportunities for child and adolescent psychiatric
research. In addition, it offers the opportunity for training in
acute or postoperative pain management problems.
Fellows spend approximately 17 hours a week over a 10-week period
at Shriners performing clinical consultations, attending a teaching
conference, and receiving supervision. All fellows have individual,
once weekly supervision with Dr. Stoddard, with additional supervision
provided by Dr. David Chedekel.
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. It is staffed by two attending child psychiatrists, Dr.
Kristine Girard (service director) and Dr. Bina Patel.
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 CHA clinic. Supervision is provided by one of the attending
child psychiatrists and by a staff pediatrician.
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 ½ 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, and Center Director, Vaughan Cate.
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.
Fellows provide one 1-hour teaching session with full center staff.
The fellow functions as a consultant without any direct clinical
responsibility.
Systems Consultation to State Agencies
The Massachusetts 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
aim of service delivery is to integrate public and private services
and resources to provide optimal community-based care and opportunities.
The Collaborative Assessment Program (CAP), which is jointly funded
and supported by DMH and the Department of Social Services (DSS),
was developed by the DMH to provide clinical consultation to DSS
regarding all cases but especially for clients and/or parents with
serious mental illness. It was also developed to help facilitate
better collaboration among the various state agencies to allow for
the best possible service and treatment plans to be offered to complicated
clients.
During this 10-week rotation, first year child psychiatry Fellows
will spend 3 hours a week accompanying the faculty during weekly
consultations to the Department of Social Services or to the Collaborative
Assessment Program in Arlington. Fellows will be supervised by Dr.
Nandini Talwar, a licensed child and adolescent psychiatrist who
has extensive experience working with community agencies. During
the consultation, the trainees will hear about complicated cases
presented by DSS case managers and supervisors and also by the Collaborative
Assessment Program. Trainees learn about services and opportunities
provided by state agencies, as well as the various dilemmas and
limitations faced by agencies when working with difficult families
and clients.
V. SPECIALTIES/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. The clinic is run by Seda Ebrahimi, PhD, and a staff of
clinicians specially trained in eating disorders.
Fellows spend 4 hours over 10 weeks every Tuesday morning getting
familiar with the Center, doing assessments and observing groups,
and helping to run treatment groups. Dr. Ebrahimi provides weekly
supervision for one hour.
Developmental Disorders/Mental Retardation/Pediatric Neurology
Fellows spend approximately 4 hours a week for 10 weeks observing
multidisciplinary evaluations at the Center for Child and Adolescent
Development in Medford, MA. 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.
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