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I. INPATIENT
Child Assessment Unit, 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 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; weekly family therapy case conference; inpatient seminar;
clinical and psychopharmacology supervision from faculty; weekly
supervision with an onsite supervisor; and informal supervision
as needed.
Teaching opportunities include: Supervising medical students, adult
psychiatrists and pediatric residents,
Adolescent Assessment Unit, Cahill 3, Cambridge 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 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 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: Weekly interview and case formulations
conference; weekly family therapy case conference; inpatient didactic
seminar; clinical and psychopharmacology supervision from faculty;
weekly supervision with an onsite supervisor; and informal supervision
as needed.
Teaching opportunities include: Supervising medical students, adult
psychiatrists and pediatric residents,
II. OUTPATIENT ROTATIONS
The Cambridge Health Alliance 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 during their Specialty/Elective
rotation 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. Preceptors provide feedback on
interviewing skills and documentation. Current preceptors are Sandra
DeJong, MD, Mark Miceli, MD, and Susan Walker, MD.
III. PSYCHIATRIC EMERGENCY SERVICE
The CHA 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 Staff Psychologists,
social workers and other experienced clinicians in Emergency Services.
Faculty supervision is available for each case seen. Christine Wittmann,
MD is the site supervisor for the PES rotation.
The Cambridge Guidance Center is a community mental health
center where fellows learn about working in the public sector by
participating in the agency's after-school program. The After-School
Program is based at The Guidance Center at 5 Sacramento Street,
Cambridge (just north of Harvard Law School). It is a DMH-funded
venture to provide a therapeutic after-school setting for 16 children
and adolescents age 6-12 who reside in the Cambridge/Somerville
area. Child psychiatry trainees spend their time co-leading groups,
doing family consultations, and assisting in the milieu. The program
director is Mary Beth Arena, LICSW. First-year fellows rotate through
the After-School Program one afternoon a week during their Psychiatry
Emergency Service block. Rotation supervisor is Charlene Zuffante,
LICSW.
Neuropsychology
During the PES rotation, residents spend one morning a week with
Laura Gaugh, PhD, observing her perform neuropsychological testing
with children and adolescents, and participating in the feedback
sessions with 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 19 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 Cambridge Hospital clinic. Supervision is provided by Dr.
Girard.
- 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 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 licensed
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, etc.
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 serve as a consultation role to high risk
and underserved families who are in need of services from more than
one agency.
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 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. Dr. Marc Libman provides clinical
supervision.
- Developmental Disorders/Mental Retardation
Fellows spend approximately 2.5 hours a week for 10 weeks during
the Specialty 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.
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