Rotations
Year 1 Program
ROTATION: Orientation to Child Psychiatry Seminar
Overall goal is to gain initial working competence in the process and content of the child psychiatric evaluation- and the basics of child psychiatric treatment paradigms, both psychotherapeutic and psychopharmacologic. Broad topics to be covered include sources of information needed for a comprehensive evaluation; commonly used screening instruments for evaluation; factors to consider when constructing a biopsychosocial formulation; individual, family, and systems considerations in developing a treatment plan; acute assessment and management; and finally, Child and Adolescent Service System (CASSP) values and principles. More specific topics also include working within the local system of care: demographics of Central MA, the mandates, organizational structure and services offered by state agencies, legal mandates, and role of family organizations in advocacy and family to family support. Lastly, an introductory series of psychopathology lectures covering the major psychiatric disorders in children will round out the seminar as a foundation for further advanced lectures, seminars, and case conferences.
ROTATION: Longitudinal Outpatient Psychopharmacology Clinic
The clinic will begin on the first Friday in July with the observation of a strength-based interview of a child and family for intake by Dr. Lutz through a one-way mirror. You may choose to incorporate this format into your preferred evaluation style, over time.
The fellow will acquire the skills to assess and diagnose patients in the outpatient setting, develop a biopsychosocial formulation, and initiate psychopharmacological treatments and/or make appropriate referrals for additional modalities of treatment. The minimum caseload is approximately 15-19 patients or 3 hours per week seeing psychopharmacology patients. The fellow will begin to accumulate cases with one new intake per week as the caseload develops. 90 minutes will be allotted for initial interviews, allowing for Dr. Lutz to review the case and meet families, while they are still in the office. The remainder of clinic time will be used for follow-up visits and supervision. The fellow will continue to develop skills in child and family assessment and learn to treat patients in a strength-based and culturally competent manner. The resident will maintain ongoing communication with the child’s primary care provider.
The resident is expected to maintain a log of all patients seen, which includes age, gender and diagnosis (Axis I including substance-related conditions, Axis II, Axis III issues that require coordination), and if the patient was seen in more than one setting. The outpatient clinic director and chief resident will assist the resident by helping to assign cases which include both genders, a variety of ages, and a breadth of diagnoses.
ROTATION: Longitudinal Psychotherapy Clinic/ Worcester Youth and Family Services
Fellows will develop skills in multiple modalities of psychotherapy with children and families including psychodynamic therapy/play therapy, cognitive behavioral therapy, and family therapy. A minimum of 4 patients a week from a combination of these three modalities should be selected or assigned. The fellow will meet with two to three supervisors (one or two psychodynamic psychotherapy 2-3 psychotherapy supervisors, one CBT supervisor, and for first-year one being a family therapy supervisor for first-year fellows one additional family therapy supervisor) for approximately one hour each per week, to review their clinic patients. The treatment should include medication management if it is indicated. The clinic is held at Worcester Youth and Family Services and each fellow is responsible for setting, maintaining, and rescheduling appointments as needed with their therapy patients during the two to three half-days in the weekly schedule allotted for this clinic. The established weekly schedule of therapy appointments should be submitted to Beth Baldwin. Subsequently, only any temporary or ongoing changes should be submitted.
ROTATION: Inpatient Psychiatry
EDUCATIONAL GOALS AND OBJECTIVES FOR 4 MONTH ROTATION
- Focus on the pharmacologic and behavioral management of adolescents hospitalized in a DMH continuing care unit
- Obtain specific experience in multi-modal treatment of these adolescents including experience in individual psychotherapy, group therapy, family therapy, and use of milieu as therapeutic environment
- Work with an inter-disciplinary team to inform a diagnostic assessment, formulation, and treatment plan for patients’ inpatient care and transition to the community
- Familiarize self with the concept of and participate in family-driven, family-centered collaborative care
- Familiarize self with battery of screening tests available in a continuing care setting
- Familiarize self with the legal statues that govern inpatient (voluntary and involuntary) hospitalization as well as psychotropic mediation treatment of children and adolescents in Massachusetts
- Learn to assess the need for chemical and/or physical restraints in the agitated and violent patient, strategies to minimize the use of restraints, and appropriate options when chemical or physical restraint cannot be avoided
- Familiarize self with both acute and more long term family intervention in the continuing care setting
- Familiarize self with the various interventions, tools, and goals of occupational therapy, including sensory integration treatments
- Familiarize self with the strategies, tools, and accommodations utilized in special education (SPED) services
Familiarize self with the state’s system of forensic admission to DMH facilities - Familiarize self with the many DMH and private referral placements children and adolescents can be discharges to the community
RESPONSIBILITIES (of Resident and of Site):
- The fellow shall carry his or her own caseload of 3-4 children and write weekly progress notes for these cases
- The fellow shall participate, and present as appropriate, in rounds, case-conferences, and multi-disciplinary teams
FACULTY RESPONSIBILITIES FOR:
TEACHING: The faculty agrees to mentor the fellow to ensure that the educational objectives are met.
SUPERVISION: The primary supervisor will be onsite during more than 50% of the of fellow’s time on the unit. The fellow and the primary supervisor will have formal supervision once per week. The secondary and tertiary supervisors will be available informally and during group meetings as well as more formally as is needed to meet the educational objectives of the fellow.
EVALUATION: The supervisors agree to provide feedback to the fellow about his or her performance continuously throughout the rotations. They agree to a formal documented evaluation two months (sooner if remediation is required) in the rotation and at the end of the rotation.
OTHER: This unit is also frequently rotated through by medical students and pre-doctoral psychology interns, which provide informal teaching opportunities for the resident. Also, additional opportunities for group psychotherapy training and supervisions are available on an elective basis.
SETTING: The unit population varies but is typically about 65% females and 35% males, 50% Caucasian, 20% Hispanic, 20% African American, and 10% Asian. Ages are from 12-19 years, with the majority being ages 15-18 years. Co-morbidity is common in the unit’s population: approximately 60-70% are diagnosed with mood disorders with or without psychotic features; 60-70% PTSD; 50-60% with various substance use disorders; 50% ODD/Conduct Disorder; 40-50% with precursors to personality disorders; 30% ADHD; 20-25% Eating disorders; 15-20% Autistic spectrum disorders, learning disorders, borderline intellectual functioning or mental retardation; and 15-20% with primary psychotic disorders. Referrals to the unit are made by acute inpatient psychiatry units in the community, through the Department of Mental Health, which does an extensive evaluation for appropriateness of referral to this level of care. Typically, patients accepted to the unit have had between 10-20 previous admissions to other acute psychiatric hospitals or residential programs. There are also several beds held for forensic admission and evaluations through the juvenile courts. There are two adjacent 15-bed units at the hospital; the census for the two units together typically runs between 27-30 patients depending on the utilization of forensic beds.
ROTATION: Pediatric Consultation-Liaison
Residents will evaluate medical and surgical patients for the presence of psychiatric illness by means of a developmentally based psychiatric interview. Residents will diagnose mental illnesses, as well as psychiatric symptoms due to medical conditions or adverse responses to medication. They will hone their ability to efficiently construct a sophisticated biopsychosocial formulation on a busy clinical service. They will develop short-term interventions and long-term treatment plans, including referrals to appropriate psychiatric services
or other systems. They will develop proficiency in interviews of families and evaluating family issues, practice teaching parent-training skills, and develop knowledge of what collateral information is important to obtain in child psychiatry. Experience will be gained in how mental illness contributes to and interferes with the management of medical conditions, and the resident will learn to assist in their concurrent management. The resident will interact with pediatricians, pediatric residents, pediatric specialists, nurses, aides, social workers, and staff from other systems of care. They will develop knowledge of the resources offered by the Department of Children and Families, the Department of Youth Services, the Department of Mental Retardation and the public school system, when these systems interface with the psychiatric issues presented in the context of the consultation. The resident will learn to serve in a liaison capacity between nurses, physicians, patients, families, and other health providers in an effective manner.
Supervision is available on-site throughout the rotation, with faculty present in the hospital. The resident will also attend C/L rounds weekly, which occur on Wednesday mornings (9:30-10:30), during which active cases are discussed by the multidisciplinary team for review of diagnostic and treatment issues.
ROTATION: Emergency Mental Health Services
PROCEDURES, GOALS AND OBJECTIVES
The resident will learn to rapidly assess patients in psychiatric emergency situations. These developmentally-based examinations will recognize the purpose of history taken from families and will include an assessment of the family system as well as community-based resources available to support the patient and family. The psychiatric evaluations will also include the need for emergent management of acute alteration in mental status, overdoses, self-inflicted injuries, and substance intoxication and withdrawal. The resident will assess the acute risk for violence, assaultiveness, self-harm, and suicide in the patient and will learn to apply criteria for inpatient psychiatric services, including situations in which such services must be obtained involuntarily. Should a parent refuse necessary inpatient hospitalization for their child, the resident will learn how to manage this circumstance, including how to apply for emergency care and protection services from the Department of Children and Families. The resident will learn to assess the need for chemical and/or physical restraints in the agitated and violent patient. They will learn strategies to minimize the use of these restraints, and appropriate options when chemical or physical restraint cannot be avoided. This will include appropriate utilization of police security services to help manage dangerous and assaultive patients.
Average caseload is one to two evaluations a day. An evaluation may take up to four hours to complete. Faculty is always available for consultation, usually on-site or (rarely) by phone. Whenever possible, faculty will directly observe the resident performing evaluations of patients. Patients seen reflect the usual cultural diversity in Worcester. Ages range from 18 months to 18 years. Patients are approximately 60% male, 40% female. Diagnoses include psychosis, eating disorders, affective disorders, oppositional defiant disorders, conduct disorders, substance abuse disorders, posttraumatic stress disorders, impulse control disorders, reactive attachment disorders, factitious disorders, autism spectrum disorders, developmental disorders, and disruptive behavior of childhood. The UMMHC emergency mental health service is a 5,000 square foot unit within the general emergency department. The pediatric waiting and evaluation rooms are completely separate from the adult section of the service. 1500 children a year receive crisis care.
ROTATION: Pediatric Neurology
PROCEDURES, GOALS AND OBJECTIVES
The resident will gain experience in gathering neurological and neuropsychiatric histories as well as in conducting neurologically-based physical exams. The resident will learn when and why specific neurodiagnostic tools are used as well as generate neurological and neuropsychiatric differential diagnoses in order to develop an understanding of when to consult neurologists and neuropsychiatrists. The resident will learn about the pharmacological management of common neurological disorders. An average caseload for a resident would consist of 3-5 evaluations per week. Evaluations may include interviews with the child or adolescent as well as their parents and family.
Objectives of the rotation include becoming proficient in neurological examination and mental status evaluation as well as interpretation of diagnostic studies including laboratory values, electroencephalograms, MRIs, and CTs. All residents receive on-site, direct supervision by faculty throughout the approximately 3 to 4 weekly hours of rotation with additional supervision provided on an individual basis if needed. There are no documentation responsibilities for this rotation.
ROTATION: Child Behavior Clinic (Infant Psychiatry)
Residents will gain competence in child psychiatric evaluation and formulation of emotional and behavioral disturbances of preschool children and in the use of short-term behavioral strategies in this population such as time-outs, sticker charts, and special time. The resident will gain knowledge in the use of rating scales (CBCL, TRF) in assessing young children. Lastly, residents gain competence in coordination of care with systems relevant to this population including pediatricians, schools, day-care providers, child protective services, etc. An average caseload for a resident in the clinic would be 1-2 cases at any given time. Supervision is provided on an immediate basis within the context of the clinic involving direct observation and feedback by the faculty. Additional supervision may be provided on an individual basis at the resident’s request. Approximately one additional hour per week outside of clinic hours is spent by the resident collecting collateral data (from teachers, pediatricians, other outside agencies) and documentation.
The clinic population is about 70% males and 30% females: 70% Caucasian, 20% Hispanic, and 10% African American. Ages is up to 6 years, with the majority of children aged 3-5 years. Co-morbidity is not uncommon in the clinic population: approximately 50% are diagnosed with adjustment disorder with mixed disturbance of conduct and emotion; 30% ODD; 25% ADHD; 20% Autistic spectrum disorders; 15% PTSD; 10% Reactive Attachment Disorder; and 5% Separation Anxiety Disorder. Referrals to the clinic are typically made by pediatricians in the community. The clinic operates on a four-session consultation model, and approximately 20 new cases per year are seen. This clinic is also frequently utilized as a training site by medical students, pediatric residents, and pre-doctoral psychology interns. These trainees primarily observe but also serve a complementary role in clinical discussions.
ROTATION: Day Care
PROCEDURES, GOALS AND OBJECTIVES
The resident will observe and interact with children age 5 and younger in a day care setting. The resident will join in the day care activities, play with individual and groups of children, read stories, and observe. The resident will gain knowledge of the range of developmental stages in preschool-aged children and appreciate gender differences in development, via the coordination of direct observation, consultation and discussion with the rotation supervisor Dr. Ciottone, and recommended readings including review of the Bayley Developmental Scale.
ROTATION: Play Seminar
The resident will gain competence in understanding how young children communicate via play, learning to recognize domains of a play-based interview that inform the mental status exam of the young child as well as recognize the developmental appropriateness of child’s behavior/play. The resident will further appreciate the importance of play as the vehicle for the child’s “voice” regarding their experience in living and gain competence in technique of play therapy, by learning about the technical considerations in play therapy (materials, use of the therapist, interaction with parents and other adults), different phases of play therapy (engagement, middle phase, termination), and indications for play therapy. Approximately 45 minutes is spent in observation of a faculty member or second year resident in a play therapy session with a child being followed longitudinally by the seminar. The remaining 45 minutes is spent in discussion, reviewing process of the session or in didactic learning about play therapy, which is based on assigned readings.
Year 2 Program
ROTATION: MCPAP Clinic
Objectives of the rotation include introduction to an outpatient consultation liaison model to primary care clinicians in central MA. Residents participate in a one time, 90 minutes long, consultative evaluation of a child or adolescents in the presence of their family. Two separate cases are usually scheduled for the clinic’s time frame. At the end of this evaluation, the referring PCP is contacted and diagnostic impressions and the treatment plan are shared. Residents learn to effectively communicate their diagnostic impression and convey the treatment plan to the PCP in a timely manner. In this rotation, residents are directly observed conducting interviews by the attending. When the resident is the primary evaluator in the case, he/she is expected to dictate a note.
PCPs contact MCPAP to request assistance in: identifying a psychiatric diagnosis, determining comorbidity, treating complicated ADHD, treating other emotional disorders, accessing care in the community, and education and training related to diagnosis, treatment and community delivery systems. When broken down by diagnosis, 32% of MCPAP care is provided to children diagnosed with ADHD, 24% with Depressive Disorders, 23% with Anxiety Disorders, 5% with Bipolar Disorder, and 6% of the children have been diagnosed with PDD. 40% of the patients have 2 or more diagnoses. Medications discussed and suggested follow similar thought with 19% of stimulant usage, 15% of SSRI, SSNI usage, 4% alpha-agonist, 4% atypical antipsychotic, but 52% of the children are on no medication.
ROTATION: School Consultation
Residents will be referred students by the school’s guidance counselor and teachers for assessment and consultation. The residents will observe the children in the classroom, confer with Dr. Ciottone, and provide feedback and suggestions to the school staff involved. Residents will become familiar with teaching techniques, classroom dynamics and the educational needs of the referred students. The resident will gain knowledge of normal child development, classroom dynamics and teaching techniques. Through direct classroom observation the resident will assess children who are not performing well for a variety of reasons. The resident will develop the ability to consider school based treatment plans in order to assist teachers to help students perform better. The resident will develop competency at working with teachers and guidance counselors in an effective and efficient manner.
Patients seen during school consult have recently been about 30% female and 70% male; also about 60% white and 30% Hispanic and 10% African American. Age range is from 6 to 12, with the majority between 6 and 10 years of age. Recent diagnoses include ODD, ADHD, separation anxiety disorder, conduct disorder, mood disorder NOS, adjustment disorder, learning disability, PTSD, and speech/language disorder. Average caseload is one or two in class observations per morning, followed by discussion and disposition planning with the school psychologist. All residents on the rotation receive continuous supervision throughout the evaluation and management process, and one on one supervision following each day's evaluations.
ROTATION: Juvenile Justice Residential Unit
The resident will develop knowledge of the criminal court systems, the range of dispositions offered, court commitments and the probations services. The resident will understand which offenses are considered, at the outside, juvenile crimes, and which offences are automatically sent to the adult courts. The resident will continue developing skills within working as member of a multidisciplinary treatment team. The resident will demonstrate increasing responsibility in provision of psychiatric care. Faculty is always available by phone for consultation on cases seen. This is a new site for this rotation beginning this year, so further information regarding this rotation likely will become available as it is developed.
ROTATION: Substance Abuse
Highland Grace House is a residential program for adolescent females with substance related disorders. It is DPH funded program, and the girls stay there for three months. Grace house is an open door program, and as such the girls’ stay there is voluntary. The resident provides psychiatric evaluation, psychopharmacological management, consultation to Grace House staff, and participates in family sessions. Dr. Lutz is present at the program every other week, and during that time the resident works closely with her. On weeks when the attending is not present, the residents acts as the primary psychiatrist to the program.
The goals of this rotation are to gain knowledge in evidence based treatment of substance use disorders in adolescents, gaining experience with diagnosing and treating such disorder, as well as their psychiatric comorbidities. The resident is also exposed to the great difference in the presentations and etiology of such disorders in youth compared to adults, and to the importance of family work to address these challenges.
ROTATION: Neurodevelopmental Disorders Consult Clinic
The resident will consolidate knowledge of the developmental disabilities of children and adolescents. The resident will become more skilled at assessing children and adolescents and interviewing their families. The resident will gain knowledge of the issues commonly seen during the child and adolescent years and the characteristic pervasive developmental delays seen in the pediatric population. The resident will enhance skills at forming alliances with children and their parents. The Clinic follows a model of 2 visits of 2-3 hours each. The first visit typically involves an extensive interview with the parent, guardian or other caretaker, focusing on developmental aspects related to the chief complaint. Between the first and second sessions, collateral data is obtained from schools, PCP’s, other providers and agencies involved in the management and care of the child. In the second session, the child is interviewed, followed by a review of the data by the resident and supervisor. Finally, initial impressions and recommendations are discussed with the guardian. Lastly, the resident generates a comprehensive report, usually between 5 and 10 pages in length.
ROTATION: Wetzel Center Latency Age Unit
- Focus on the pharmacologic and behavioral management of psychiatrically hospitalized latency aged children
- Obtain specific experience in multi-modal treatment of latency aged psychiatrically hospitalized children
- Work with an inter-disciplinary team to formulate treatment plans for the inpatient work and transition to the community
- Become more familiar with the different modes of care for children with serious emotional disturbance (i.e., family stabilization, partial hospitalization, day programs, after-school programs)
- Familiarize his/herself with battery of screening tests available in an acute setting (i.e., screening for suicide and/or Asperger’s disorder)
- Familiarize herself with both acute and more long term family interventions in the acute setting
- The fellow shall carry his or her own caseload of 4 children
- The fellow shall participate in rounds, case-conferences, and multi-disciplinary teams
- The fellow shall present each child on his/her caseload at least once (more if necessary) during a case-conference
ROTATION: Longitudinal Outpatient Psychopharmacology Clinic
The clinic will begin on the first Friday in July with the observation of a strength-based interview of a child and family for intake by Dr. Lutz through a one-way mirror. You may choose to incorporate this format into your preferred evaluation style, over time.
The fellow will acquire the skills to assess and diagnose patients in the outpatient setting, develop a biopsychosocial formulation, and initiate psychopharmacological treatments and/or make appropriate referrals for additional modalities of treatment. The minimum caseload is approximately 15-19 patients or 3 hours per week seeing psychopharmacology patients. The fellow will begin to accumulate cases with one new intake per week as the caseload develops. 90 minutes will be allotted for initial interviews, allowing for Dr. Lutz to review the case and meet families, while they are still in the office. The remainder of clinic time will be used for follow-up visits and supervision. The fellow will continue to develop skills in child and family assessment and learn to treat patients in a strength-based and culturally competent manner. The resident will maintain ongoing communication with the child’s primary care provider.
The resident is expected to maintain a log of all patients seen, which includes age, gender and diagnosis (Axis I including substance-related conditions, Axis II, Axis III issues that require coordination), and if the patient was seen in more than one setting. The outpatient clinic director and chief resident will assist the resident by helping to assign cases which include both genders, a variety of ages, and a breadth of diagnoses.
ROTATION: Longitudinal Psychotherapy Clinic/ Worcester Youth and Family Services
Fellows will develop skills in multiple modalities of psychotherapy with children and families including psychodynamic therapy/play therapy, cognitive behavioral therapy, and family therapy. A minimum of 4 patients a week from a combination of these three modalities should be selected or assigned. The fellow will meet with two to three supervisors (one or two psychodynamic psychotherapy 2-3 psychotherapy supervisors, one CBT supervisor, and for first-year one being a family therapy supervisor for first-year fellows one additional family therapy supervisor) for approximately one hour each per week, to review their clinic patients. The treatment should include medication management if it is indicated. The clinic is held at Worcester Youth and Family Services and each fellow is responsible for setting, maintaining, and rescheduling appointments as needed with their therapy patients during the two to three half-days in the weekly schedule allotted for this clinic. The established weekly schedule of therapy appointments should be submitted to Beth Baldwin. Subsequently, only any temporary or ongoing changes should be submitted.
ROTATION: Play Therapy Seminar
The resident will gain competence in understanding how young children communicate via play, learning to recognize domains of a play-based interview that inform the mental status exam of the young child as well as recognize the developmental appropriateness of child’s behavior/play. The resident will further appreciate the importance of play as the vehicle for the child’s “voice” regarding their experience in living and gain competence in technique of play therapy, by learning about the technical considerations in play therapy (materials, use of the therapist, interaction with parents and other adults), different phases of play therapy (engagement, middle phase, termination), and indications for play therapy. Approximately 45 minutes is spent in observation of a faculty member or second year resident in a play therapy session with a child being followed longitudinally by the seminar. The remaining 45 minutes is spent in discussion, reviewing process of the session or in didactic learning about play therapy, which is based on assigned readings.