Child Psychiatry Curriculum

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. The first year experiences are designed to introduce fellows to several of the settings where they can be future leaders in the field of child and adolescent psychiatry. 

Rotations: First Year

Experiences in Inpatient and Intensive Residential Treatment Programs

• Child Inpatient Unit and Adolescent Inpatient Unit, Somerville Hospital
  These robust clinical experiences give 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 other faculty.
  
  Patients range in age from 3 to 12 on the Child Inpatient Unit and 13 to 17 on the Adolescent Inpatient Unit. Patients and families represent a diverse socioeconomic, ethnic, and cultural mix and present with a wide range of diagnostic problems, including post-traumatic, disruptive, mood, psychotic, substance use disorders, and developmental disorders. Clinical focus is on accurate diagnostic assessment, including individual and family evaluations and broad-based treatment such as psychopharmacology, family work and milieu therapy. Systems work includes school, social service and program (residential) consultation. The Child Inpatient Unit has received recognition for its development of strategies to reduce the use of restraint and seclusion. Both units have also developed a family-centered model of care.
• Neurodevelopmental Unit, Somerville Hospital
  This 4 week clinical experience is designed to teach fellows about the assessment, diagnosis, formulation, and treatment planning for children and adolescents with neurodevelopmental and/or genetic disorders requiring hospital level of care. Fellows work as part of a multidisciplinary team, consisting of the attending child psychiatrist, team social worker, care manager, unit nursing staff, unit milieu staff, inpatient psychologist, and occupational therapy staff to learn about the treatment  landscape for this patient population.
• Intensive Residential Treatment Program (IRTP)
  Fellows spend 2 weeks at the Merrimack Center and Centerpoint IRTPs, two intensive residential programs that provide trauma-informed, evidence-based care for adolescents with serious emotional disturbance and major mental illness. The Merrimack Center specializes in working with youth with intellectual disabilities and other neurodevelopmental challenges such as Autism Spectrum Disorder.
• Therapeutic Residential School
  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 will participate in treatment teams, groups, and milieu treatment of students at the residential school.

Experiences in Assessing Patients in Emergency Psychiatry, Psychiatry Urgent Care, Multidisciplinary Outpatient Evaluation Team

• Cambridge Hospital Psychiatric Emergency Service (PES)
  The PES is a consultation service based in the medical emergency room. It provides evaluation and urgent treatment to children, adolescents, adults, and families. As part of the PES team, fellows see children and adolescent patients under age 18. Emergency assessments are directed at conducting risk assessments and determining patient needs for acute stabilization and appropriate/least restrictive level of care.
• Psychiatric Urgent Care
  The psychiatric urgent care provides urgent evaluation, and bridge visits/follow-up appointments for children and adolescents awaiting connection to longer-term outpatient care. Urgent evaluations have a focus on conducting risk assessments and determining the appropriate level of care.
• Multidisciplinary Team Evaluation Clinic
  The Evaluation team is multidisciplinary (psychiatry, psychology, social work, nursing, medical students) and provides in-depth initial assessments of children and families over two sessions. This setting provides an excellent opportunity for fellows to observe senior faculty interview patients, receive direct feedback on their own interviewing skills, practice in-depth bio-psycho-socio-cultural formulation skills (both written and in presentation to the team), learn about local resources and systems available for families, and to work together in a team setting to think through diagnostic formulations and treatment plans.

Experiences in Early Childhood Development and Neurodevelopmental Disorders

• Neurodevelopmental Clinic
  First year fellows spend the rotation assisting in the evaluation of children in the Neurodevelopmental Clinic. This clinic is a service within the Division of Child Psychiatry that provides evaluation, consultation, and treatment for children referred for concern of serious neurodevelopmental disorders such as Autism Spectrum Disorder (ASD) and Intellectual Disability (ID). Evaluations include extensive review of developmental history developmental assessment, review of neuro/psychological, academic, and Early Intervention evaluations, collateral from families and outside supports, and often a developmental assessment scale.
• Pediatric Neurology
  The fellows rotate 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. 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.
• Early Intervention Observation
  Fellows spend three mornings with the Early Intervention program at Riverside Community Care observing home based assessments. Fellows learn how preventive strategies are practiced in a state-supported program.
• Preschool Observation
  Fellows will spend three mornings with a child psychiatrist observing children at The Peabody Terrace Children’s Center, a preschool/daycare in Cambridge, MA. Fellows will have the opportunity to observe and discuss typical young childhood development
• Relationship Based Behavioral Treatment
  Fellows will spend an hour a week with a psychologist to engage in a combination of discussion of relationship based behavioral treatments, video review of young children with a range of challenges, and case discussion of their own patients when relevant. Discussion will include a continuum of relational to behavioral and integrated treatment with a focus on integrated treatment.
• Global Parent-Infant Mental Health
  Fellows will meet weekly with a psychiatrist for a Global Infant Parent Mental Health (GIPMH) training experience. Global Infant Parent Mental Health includes the developmental science and mental health clinical treatment of infants and parents in the perinatal period. The rotation consists of (1) a reading tutorial in developmental psychology; (2) reviewing videotaped illustrations of infant development and infant-parent interactions; (3) introduction to videotape microanalysis; (4) demonstrations of the interventions of Newborn Behavior Observation (NBO); and (5) discussions of cultural issues in IPMH with guest experts.

Consultation/Liaison Work - Inpatient, Outpatient and Community Systems of Care

• Inpatient Consultation-Liaison
  Located in the western suburbs of the Boston area, Newton-Wellesley Hospital is a community hospital that is a member of the Mass General Brigham. 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, eating disorders, pain management, and problems managing chronic illness. Fellows are also available to help with ED consultations where they conduct evaluations directed at conducting risk assessments and determining patient needs for acute stabilization and appropriate/least restrictive level of care.
• Outpatient Child & Adolescent Mental Health integration Service (CAMHI)
  The Child & Adolescent Mental Health integration (CAMHI) Service at CHA Cambridge Pediatrics Clinic gives first-year fellows the opportunity to work in an integrated care model. 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, staffing and the role pediatricians play in the mental health care for patients. Fellows will learn how the child psychiatrist on an integrated care 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.
• 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 rotation, first-year child psychiatry fellows will spend time each week accompanying the faculty during weekly consultations to DMH and DCF at various sites within our catchment area.
• Riverside Community Care
  This rotation introduces fellows to wrap-around services offered in the setting of a community mental health center. These services are offered through the Massachusetts’ Children’s Behavioral Health Initiative (CBHI), an innovative statewide reform of public child mental health care emphasizing strengths-based, wrap-around community supports. Fellows join the staff on home visits and sit in on their team and provide consultation to the clinicians on their cases.  Fellows also have the opportunity to observe their day treatment program, which is funded by DMH and specializes in youth who are experiencing early onset psychosis or who are at high clinical risk.

Experiences in Substance Use Assessment and Treatment

• Substance Abuse Rotation
  Fellows will rotate through the Adolescent Substance Abuse & Addiction Program (ASAP), an outpatient clinic at Boston Children’s Hospital (BCH). Fellows will observe members of ASAP’s multidisciplinary team (which includes pediatric and/or child & adolescent psychiatry physicians, nurse practitioners and social workers). Treatments observed may include individual and/or group therapy, psychopharmacology visits, and medication assisted treatment.
• Independent Elective/Scholarly Activity
  Fellows have designated elective time during the CAP1 Year to pursue scholarly activities or quality improvement in their own particular area(s) of interest, meet potential mentors, and set the foundation for the protected clinical scholarship and elective time in the second year.

Longitudinal Outpatient Experience – First Year

The Cambridge Hospital Child and Adolescent Outpatient Service is located at the Macht Building (on the Cambridge Hospital Campus) and provides evaluation and treatment to children from ages 2 to 17 and treats patients with a wide range of developmental, educational, emotional, behavioral and psychiatric issues. The clinic serves a racially, ethnically, and socioeconomically diverse population.

In addition to the Cambridge Hospital based outpatient service, children and adolescents are seen by our staff at our Malden Outpatient Clinic, local school-based health centers, at CHA community pediatrics and family medicine clinics in an integrated primary care model, 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).

• Outpatient Psychotherapy Clinic
  Fellows spend their time learning and providing psychotherapy and psychopharmacology to diverse populations. This 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 per week, primarily for psychotherapy, but also for evaluations, family work and case management. Each first-year fellow has two therapy supervisors who they meet with for one-on-one 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 attending child psychiatrists who are available to help fellows with diagnostic interviewing and treatment planning, to answer clinical questions and to guide fellows’ self-directed learning about evidence-based treatments in clinical practice. 

Longitudinal Outpatient Clinics

Outpatient Psychotherapy Clinic
Second-year fellows continue their work in evaluating and treating children and families. The emphasis is on a flexible approach and increasing each fellows’ breadth and depth of treatment modalities. The fellows are expected to have a minimum of seven clinical hours of outpatient psychotherapy, including co-leading a weekly group. Second-year fellows receive robust weekly outpatient supervision. This includes 4 individual supervision for psychotherapy (individual, group, and family therapy) in addition to group-based CBT supervision, group-based Gender and Sexuality supervision, and group-based supervision for school consultations.

Precepted Psychopharmacology Clinic
Second-year fellows spend at least 7 hours per week throughout the year performing psychopharmacology evaluations and medication management in a split-treatment model. Fellows spend roughly half of their time at the CHA Macht/Cambridge Hospital Outpatient Psychiatry Clinic and the other half at one of our community-based sites, including CHA Malden Outpatient Psychiatry Clinic, CHA Everett High School Teen Health Center, Cambridge Rindge and Latin High School Teen Clinic, or Riverside Community Care in Somerville. Preceptors provide feedback on interviewing skills, treatment planning, coordination of care, and efficient coding and documentation. Time each week is devoted to supervision of cases and didactics focusing on the review of seminal articles in pediatric psychopharmacology.

Community Consultation/Liaison

School Consultation
The Cambridge Public School system serves a diverse ethnic and socioeconomic community from kindergarten through grade 12. Child psychiatry fellows spend three hours per week for nine months assigned to an elementary school, middle school, or high school. Fellows have an opportunity to be an integrated part of their school’s student support team and complete evaluations of students with safety and/or mental health concerns (e.g. aggressive behavior) in the school setting and under close supervision.

Forensic Consultation
Asylum Evaluations: CHA works with the nonprofit, Kids in Need of Defense (KIND) to provide mental health evaluations for children seeking asylum in the United States. Under the supervision of Dr. Malak Rafla, 2nd-year fellows complete at least one asylum evaluation during the year. The evaluation typically includes writing an affidavit for immigration court, and may involve testifying if requested as part of the case.

Juvenile Court: Adolescent Consultation Services (ACS), located in Cambridge, is a private non-profit agency which operates the Juvenile Court Clinics for the Middlesex County Juvenile Courts. Upon order of the Judge, Juvenile Court Clinic staff conduct comprehensive diagnostic evaluations of youth and families involved in the court. Educational activities include learning sessions on a variety of court related topics and experiential instruction on how to review relevant collateral documents and prepare comprehensive forensic reports. Fellows alo have an opportunity to observe juvenile court.

Elective/Scholarly Activity/Group Quality Improvement

Fellows have the equivalent of one day a week in the second year to pursue clinical activities according to their particular interests. Fellows are expected to either create an elective proposal or choose from a variety of electives currently offered by our faculty.

Every fellow also completes a scholarly project by the end of the second year. In the past, fellows have chosen a wide range of projects, including: conducting a pilot research project on pharmacological treatment of weight gain in adolescents on neuroleptic medications; developing a school-based curriculum on cyber-bullying; and incorporating screening for food insecurity into the Child and Adolescent Outpatient Psychiatry Department.

In addition, fellows work together to complete a longitudinal group quality/performance improvement project, focused on supporting health equity among our patients. Each of these experiences may be mentored by faculty within or outside of CHA.

A prized feature of our didactics is the Harvard Consolidated Seminar Program. In this program, first-year fellows in Harvard-affiliated child psychiatry training programs (Cambridge Health Alliance and Boston Children’s Hospital) come together to participate in a 3-hour seminar program. Internationally renowned Harvard faculty and guest lecturers on a variety of topics in child mental health research, assessment and treatment.

Additionally, we have robust CHA-based seminars in both years of fellowship that cover multiple different topics within the field of child and adolescent psychiatry.

We also have a joint training meeting with both classes that meets twice a month and a monthly joint peer support group led by a facilitator. 

Family Therapy is often a core component of any successful psychiatric treatment of a child or adolescent and the CHA child psychiatry fellowship offers a very strong grounding in Family Therapy training opportunities. These opportunities aim to provide fellows with a basic conceptual understanding of family therapy as well as a range of experiences across treatment settings with diverse families and family issues.

In the first year, fellows participate in a year-long seminar that introduces Family Therapy theory, assessment, and intervention. The seminar consists of didactics and observation of family consultations using a one-way mirror, with a daylong “Family Therapy Retreat” to wrap-up the academic year. The focus of this seminar is on acquiring basic knowledge, skills and attitudes in working with family systems.

In the second year, an advanced elective seminar is offered which provides clinical training in Family Therapy through case consultation and live supervision using a one-way mirror. Individual supervision for family therapy cases seen during both years of fellowship is offered by members of the faculty who specialize in family therapy.

Fellows also participate in inpatient Family Consultations, conducted on both the Child Inpatient Unit and the Adolescent Inpatient Unit.

The Program in Psychodynamics is an elective opportunity for fellows in both years across all three Harvard Child Psychiatry Fellowship programs. Its goal is to foster the career development of fellows with an interest in psychodynamic psychotherapy, psychodynamic research, and psychoanalysis. The core activity is a monthly dinner meeting hosted by program faculty to discuss relevant topics in the context of case presentations. In collaboration with the Boston Psychoanalytic Society and Institute (BPSI), the Program in Psychodynamics allows fellows to enhance and deepen their psychodynamic interests and to integrate psychodynamic scholarship into the rigorous clinical training provided to all CHA child psychiatry fellows. Fellows may choose to pursue an elective with BPSI during their second year.

All our fellows are required to teach during their child training. Fellows have a hands-on, interactive "Learning to Teach" seminar in the summer of their second year. They can then choose teaching responsibilities based on their interests. In the past, fellows have co-taught seminars, taught medical students and general psychiatry residents on the inpatient units and outpatient evaluation teams, given lectures as part of standing seminars, supervised adult residents in their child therapy cases, developed curricula for public education, given talks in community settings, and helped organize and teach in CHA/HMS continuing medical education courses.

Throughout their training, fellows work to provide compassionate, competent psychiatric care to sexual and gender minority children, adolescents, and families. Second-year trainees work with a youth struggling with LGBTQ related issues in weekly psychotherapy. Trainees receive bi-weekly clinical supervision, teaching, and consultation in supporting care of this patient population.

Our fellowship program aims to develop leaders in community child and adolescent psychiatry who are equipped to improve the lives of vulnerable populations. To support fellows in this effort, we have created the Health Equity, Improvement, Scholarship, and Leadership (HEISL) curriculum within our program. Throughout both years of training, fellows will participate in seminars as well as group and individual projects to learn the knowledge, skills, and behavior required to be leaders in improving the health and care for families in need. Through a guiding framework of health equity, fellows will learn about important principles and practices such as: social determinants of health and structural competency, implicit bias in child psychiatry, coproduction of healthcare, population mental health,, health disparities research, quality and performance improvement science, change leadership, and personal narrative and advocacy. The HEISL curriculum is structured around a 1.5 year-long group quality/performance improvement project targeting a barrier of health equity for our patients.

We are dedicated to helping fellows pursue their interests in child & adolescent psychiatry through scholarship activities. In the Department of Psychiatry at Cambridge Health Alliance and at Harvard Medical School, scholarship is defined broadly and may include the scholarship of discovery, the scholarship of integration, the scholarship of teaching and the scholarship of application.
The scholarship requirement of the Child Psychiatry Fellowship program is designed to meet the ACGME requirements and provide flexibility for fellows to pursue their own interests. While all clinical service experiences, supervision and seminars are an integral part of developing scholarship, specific components are intended to address the development of attitudes, skills, knowledge, and behaviors that lead to innovation and leadership in the field. These include:

1. Introduction to scholarship themes and techniques in the Health Equity, Improvement, Scholarship, and Leadership seminars during first and second years.
2. Clinical Scholarship Seminar, in the second year, learning how to develop, finish, and present a clinical scholarship project.
3. Longitudinal Group Quality/Process Improvement Project  of the class’ choosing that focuses on health equity.
4. Seminars in research literacy and evidence based practice.
5. Journal Club
6. Opportunity to apply for CHA Clinical Learning Environment Innovation Awards Program, a small grants program offering trainees a stipend to support initiatives that will improve patient experience of care and staff experience of caring for our patients.
7. Case and topic-specific presentations during rotations, seminars and specialized forums including the Child Complex Case Review Conference (CCRC) and/or the Patient Safety/Difficult Case Conference.
8. Option of preparing a poster for Harvard Psychiatry Research and Mysell Day and CHA Academic Poster Day, as well as support for presenting scholarly work in venues such as Grand Rounds.
9. Institutional support and funding to present original scholarly work at local, regional and national conferences.
10. Completion and presentation of a scholarly project 

Fellows have four to six hours of supervision per week. For first-years, this includes supervision from two individual therapy supervisors, a psychopharmacology clinic supervisor and rotation supervisors.

In their second year, fellows have supervisors in the areas of individual, family, group, behavioral therapies, and gender/sexuality issues, as well as two psychopharmacology clinic supervisors. They also have supervisors for each rotation including school consultations and forensic evaluations.

In addition, first and second year fellows have an administrative supervisor who helps fellows learn to manage their clinical and administrative commitments effectively and efficiently.