Child and Adolescent Psychiatry Fellowship Clinical Rotation Sites
UC Davis Psychiatry Outpatient Clinic
The faculty in this clinic consists of three child psychiatrists. The clinic is also staffed by other attending psychiatrists who treat adult and geriatric patients.
In the first year, each fellow is individually supervised weekly by a faculty child psychiatrist, and additionally by another child psychiatrist from either the volunteer or full-time clinical faculty. In the second year, fellows are supervised in a group by a faculty child psychiatrist and for an hour individually by another child psychiatry faculty (either volunteer or full-time clinical faculty).
The clinic population is approximately 58% male, 42% female; 63.8% Caucasian, 16.2% Hispanic, 15.2% African American, and 4.8% Asian. The age range is 3-18 years, with approximately 35% from lower socioeconomic groups and 65% from middle socioeconomic groups. The age distribution is as follows: 12% 3-6 year olds, 42% 7-11 year olds, 19% 12-14 year olds, 27% 15-18 year olds.
Diagnoses in the clinic vary and many children have multiple diagnoses: attention deficit hyperactivity disorder/disruptive behavior disorders 31%, mood disorders 37%, psychotic disorders 4%, anxiety disorders 12%. Other disorders (including pervasive developmental disorders, Tourette's disorder, mental retardation, substance-related disorders, learning disorders, enuresis/encopresis, and attachment disorders) account for 16%.
Treatment modalities include individual psychotherapy (brief, long-term, psychodynamic, cognitive-behavioral, supportive and crisis-oriented), family therapy, and psychopharmacologic interventions. This is a managed-care clinic.
First-year fellows are scheduled approximately four new patient evaluations per month and approximately 16 follow-up patient appointments a month. Second-year fellows are scheduled approximately 12-16 follow-up patient appointments per month. The average case load by the end of the first year and throughout the second year is approximately 16-20 patients. Fellows assume responsibility for all aspects of patient care in this clinic, including psychotherapeutic interventions, psychopharmacologic interventions (if indicated), family therapy, and any consultation to or collaboration with school or outside agencies. Fellows are expected to develop a caseload of four cases in long-term psychotherapy.
Neurodevelopmental Disorders/Psychopharmacology Clinic (UC Davis MIND Institute)
Fellows receive direct, on-site supervision from an attending faculty child and adolescent psychiatrist. Medical students and other trainees provide opportunities for teaching.
Patients seen in these clinics range in age from three months to 18 years. The majority of the patients seen in the clinics treating pervasive developmental disorder (PDD) spectrum disorders are male. Patients represent a broad range of ethnicities and cultural backgrounds. The majority of patients treated in the psychopharmacology clinic are diagnosed with some form of PDD and/or mental retardation. Patients in this clinic may also be diagnosed with mood disorders, anxiety disorders, disruptive behavior disorders, and occasionally psychotic disorders. Many patients also have other medical and developmental disorders, including seizure disorder, Down Syndrome, metabolic disorders, asthma, Fragile X, and other genetic disorders. Fellows perform psychopharmacologic, educational, and behavioral interventions in this clinic. In the pediatric neurology clinic, presenting concerns and diagnoses often include seizure disorder, headache, cerebral palsy, genetic syndromes, PDD spectrum disorders, and concerns regarding infant hypotonia or developmental delays.
Fellows directly evaluate and treat patients. They receive on-site supervision by faculty who observe their clinical work from behind a one-way mirror. Fellows then dictate evaluations and progress notes for faculty review.
Pediatric Consultation Liaison (UC Davis Children's Hospital)
The faculty consists of a child and adolescent psychiatrist. Pediatric consultation liaison rounds are held regularly and include medical students and psychology interns. All team members have an opportunity to present at weekly.
Services provided include psychiatric evaluation of children, adolescents, and families with associated treatment recommendations; working with the primary treatment team to facilitate their understanding and management of a range of emotional, behavioral, and systems issues affecting the child; ongoing treatment, including recommendations for medication management and behavioral interventions; and provision of short-term and cognitive behavioral therapy. Services are coordinated with the Child Life Program and Pediatric Social Services, along with the primary consulting medical/surgical team. Medical conditions for which psychiatric consultation is sought are of a great variety but include: suicide attempts, accidents, victims of violence and abuse, cancer, cystic fibrosis, delirium, pulmonary, endocrine, infectious disease, cardiology, and renal problems. The population is approximately 58% male and 42% female; ages range from infancy to 18 years. The population is approximately 51% Caucasian, 32% Hispanic, 9% African American, and 8% Other. Approximately 32% of the psychiatric diagnoses made are mood disorders, 22% adjustment disorders, 16% ADHD and disruptive behavior disorders, 12% PTSD and other anxiety disorders. The remainder represents a range of disorders, including psychotic disorders, delirium, and mental retardation.
The service receives approximately 16-24 new consultations a month. A typical caseload for a child psychiatry fellow is 2-5 cases. The short-stay nature of some of the pediatric services means that an evaluation and disposition often needs to be provided in one to three days, although some of the consults may come from services with longer lengths of stay. Consultations are often requested by trauma surgery, pediatric intensive care, obstetrics (maternal competency), and emergency services. Cases are worked up and managed primarily by the fellow, but are reviewed concurrently with the faculty supervisor. The supervisor often observes the fellow interviewing a child and his/her family and interacting with pediatric fellows and other members of the treatment team, and so is able to provide supervision to fellows around these interactions.
Individual supervision is available daily when the fellow is on the service. Group supervision is scheduled twice a week and includes medical students. The fellow is also expected to provide at least one hour a week of teaching to the medical student in addition to the usual clinical supervision.
Latency Inpatient (Sutter Center for Psychiatry)
This is a required first year, four-month rotation at Sutter Center for Psychiatry, with focus on evaluation and treatment of latency-aged children. Three board-certified child and adolescent psychiatrists staff the site. Fellows are directly supervised by these psychiatrists and also work closely with educational, nursing and social work staff, and mental health workers. Direct on-site supervision is provided.
Fellows carry up to four cases on this rotation. They are responsible for performing comprehensive initial assessments under direct supervision of the attending psychiatrist, and generating an appropriate differential diagnosis and biopsychosocial treatment plan. Individual psychotherapy and psychopharmacologic management is provided by the fellow under supervision. The fellow works directly with social work staff to assess and treat the family. Fellows collaborate closely with county social workers, foster agency workers, child protective services, children’s attorneys, and others in the provision of care.
Outpatient Clinic (Sacramento County Outpatient Clinic and Minor Evaluation Response Team)
Fellows rotate through the Sacramento County Health and Human Services Child and Adolescent Psychiatric Services during their second year of training. In their first year, fellows evaluate and assess children and adolescents in crisis during their rotation with the Minor Evaluation Response Team (MERT). The outpatient clinic is staffed by three faculty child psychiatrists, three faculty psychologists, a full-time nurse, and several master's level clinicians. The crisis unit is staffed by a child psychiatrist, a psychiatric nurse, and several bachelor's and master's level clinicians.
Fellows have weekly individual supervision with faculty child psychiatrists in the outpatient clinic, and meet with an attending clinical child psychologist for one hour per month to discuss issues in psychological testing. Fellows on this rotation also participate in a weekly multidisciplinary assessment conference in which children and adolescents treated within the community mental health setting are comprehensively assessed over four to five 90-minute sessions. Assessment includes a review of records, interview with caregiver, interview with child, report of school observation, psychological testing, and family assessment. This conference is attended by child psychiatry fellows, child psychology post-doctoral students, child psychiatry and child psychology faculty and staff, a faculty pediatrician, medical students, social workers, and bachelor or masters level therapists. The conference focuses upon assessment, diagnosis, formulation, and development of a comprehensive biopsychosocial treatment plan.
The county child/adolescent mental health population is approximately 60% male, 40% female, 47% Caucasian, 24% African American, 12% Hispanic, 3% Asian, and 14% Other. The age range is three to 18 years. The county serves the Medi-Cal and indigent child/adolescent population. Child protective services is involved in approximately 37% of cases, 6% are involved with probation, and 2% are involved with the California Department of Developmental Services Regional Centers for the developmentally disabled. Additionally, 6.4% are enrolled in "26.5 services" (which designate them as eligible for the most intensive educational services due to their emotional/educational difficulties). Non-ADHD disruptive behavior disorders account for 22% of the cases seen, ADHD 11%, depressive disorders 13%, bipolar disorder 5%, adjustment disorders 16%, anxiety disorders 14%, with the remainder carrying other diagnoses. Many children at these sites carry multiple psychiatric diagnoses. In the outpatient clinic, many of the cases involve fairly complex biopsychosocial treatment planning. Fellows work as part of a multidisciplinary team within a continuum of care, and work both individually with patients, as well as with families. They consult to mental health coordinators around diagnostic assessment, recommendations regarding level of care and specific interventions, and make recommendations for any pediatric follow up, parental referral for services, or social service interventions. At this site, consultation is often provided to other community agencies as well, including foster agencies, group homes, probation, protective services, and wrap-around programs.
In the crisis unit, most patients are on involuntary holds. Risk assessments are performed with particular attention paid to assessment of medical stability and identification of medical issues related to psychiatric concerns. The basic treatment mode is crisis intervention. Fellows manage acutely agitated, and sometimes violent or psychotic patients. Fellows generate multiaxial diagnoses and develop an appropriate disposition and treatment plan, based on direct interviews of the patients and their caretakers, collaboration with other crisis clinicians, and collateral information. If patients are to be discharged from the crisis unit, fellows make recommendations regarding the child or adolescent's needs in the community.
In the outpatient clinic fellows are typically scheduled for one intake per week and maintain an ongoing caseload of approximately 10-20 patients. In the crisis unit, fellows evaluate one to four patients per week.
Fellows receive individual supervision by faculty child psychiatrists at the outpatient clinic. Fellows in the intake stabilization unit are supervised on site by a faculty child psychiatrist.
Adolescent Inpatient Unit (Heritage Oaks Hospital)
This is a required rotation for four months at the inpatient adolescent service at Heritage Oaks Hospital. One faculty child psychiatrist staffs this site. Additionally, fellows work with hospital-based social workers, nursing staff, internists, and mental health workers.
Direct on-site supervision is provided. Fellows round daily with the attending child psychiatrist, medical student, and occasional general psychiatry fellow. Hence, significant opportunities for teaching are available at this site. A weekly journal club is included.
This is an adolescent unit. The child/adolescent mental health population is similar to county numbers and approximately 60% male, 40% female, 47% Caucasian, 24% African American, 12% Hispanic, 3% Asian, and 14% other. Cases of major mood disorders and psychotic disorders are frequently seen. Most adolescents treated on this service are diagnosed with multiple co-morbid disorders as well, including anxiety disorders, substance use disorders, disruptive behavior disorders, and parent-child relational problems. A significant number of children treated on this service have histories of abuse and/or neglect; many reside in foster or group homes. Treatment provided in hospital includes milieu, group therapy, individual psychotherapy, family therapy, psychopharmacology, art therapy, and recreation therapy.
Fellows carry 3-4 cases during this rotation. They are responsible for performing comprehensive initial assessments under direct supervision of the attending psychiatrist, and generating an appropriate differential diagnosis and biopsychosocial treatment plan. Individual psychotherapy and psychopharmacologic management is provided by the fellow, under supervision. The fellow works directly with social work staff to assess and treat the family. Fellows collaborate closely with county social workers, foster agency workers, child protective services, children's attorneys, and others in the provision of care.
Forensic Psychiatry (Sacramento County Youth Detention Facility)
The Sacramento County Youth Detention Facility (YDF) is a required rotation in the first year of child psychiatry fellowship training providing experience in forensic child psychiatry. The rotation consists of one half day per week for a duration of 4 months. YDF is the first point of interaction for most youth who enter the county's juvenile justice system. YDF provides a safe and secure environment for these youth as well as provides educational and vocational activities that promote the health and well-being of the youth served; encourages law-abiding behavior; teaches individual accountability for one's choices; and models pro-social behaviors.
Faculty at this site consists of one child psychiatrist. The fellow interacts with multiple other non-faculty mental health professionals, including probation officers, teachers, social workers, pediatricians, nurses and other YDF staff.
Fellows work directly with the on-site attending child psychiatrist to provide consultation to probation officers working with incarcerated youth identified as having special needs. Fellows provide diagnostic impressions and advice to probation officers and YDF mental health staff. Fellows provide brief trainings on pertinent mental health topics to the special needs unit probation officers at least twice per month.
Fellows gain knowledge of the Juvenile Justice System as it interfaces with mental health services and gain an understanding of the role biopsychosocial factors play in the development of conduct disorder and substance abuse disorders. Fellows will also be assigned forensic assessments ordered by the Sacramento County Juvenile Justice Courts as available. These assessments, when available, are directly supervised by the on-site attending child psychiatrist.
The age range of youth at YDF is between 12 and 19 years old with the majority falling within the 15-18 year old age range. The entire population has a positive criminal history and many of them are repeat offenders.
Diagnoses of youth identified with special needs vary and many children have multiple diagnoses. Common diagnoses include disruptive behavior disorders, substance abuse and substance dependence. A significant number of children with attention deficit/hyperactivity disorder, mood disorders and anxiety disorders are seen. Intellectual problems and learning disabilities are frequently identified.
Treatment modalities are limited as the rotation’s purpose is to provide consultation to probation officers working with youth in the juvenile justice system identified as having special needs.
Goals of the rotation are to gain an appreciation of the juvenile justice system and to gain competence in assessing criminally involved youth. Fellows will develop skills in collaboration with non-physician colleagues such as probation officers and mental health clinicians. Fellows will develop an appreciation of the various roles played by members of the juvenile justice system. Fellows will develop an appreciation of the role probation officers play in the lives of juvenile delinquents.