Child and Adolescent Psychiatry Outpatient Clinic
(OHSU) (Institution 1.1a)
- Required rotation occurring throughout the first and second year. Time requirement varies depending on the residents’ other rotations, from 40-50% in the first year, and 60-80% in the second year.
- Faculty consists of 1 child psychiatrist Clinic Director and two other OHSU child psychiatry faculty, who provide required clinic-based supervision and are available on a daily basis for consultation around clinical issues. Weekly outpatient supervision (off-site) is provided by six additional clinical faculty.
- The outpatient rotation is an integral part of the training program and is continuous during the two years of the residency. This allows for maximum continuity of treatment cases of varying duration. The didactic portion of the program consists of 6-7 hours per week of seminars and case conferences and runs concurrently with the clinic experience during the two years of training. Outpatient cases are integrated into the weekly Clinic/Case Conference seminar including case presentations by fellows and residents.
- During the most recent academic year, the Clinic’s visits divided between males and females. Ongoing review of children and adolescents seen indicates that they generally parallel the population of the Portland and surrounding area, with the vast majority being Caucasian, along with smaller percentages of Hispanic, Asian, African American and Native American. The Clinic provides services to all these ethnic groups. Work with parents and families are a regular part of the clinical activity. The clinic serves Medicaid and privately insured children. The age range varies from less than 1 year to age 18, although some patients between ages 18-21 are seen if they are still in high school and/or living at home. The majority of patients are school age and adolescent. A much smaller percentage is under 6 years of age. According to past surveys, approximately 30% have Disruptive Behavior Disorders (including ADHD), 20% Depression or Dysthymia, 20% Anxiety Disorders (including PTSD), 15% Adjustment Disorders, and 5% Developmental Disorders. Early onset psychotic and bipolar disorders are increasingly recognized. Many of the above diagnoses are comorbid in the clinic population. Residents learn multiple treatment methods including psychodynamic therapy, parent training, pharmacotherapy, collaborative problem solving, cognitive-behavioral therapy, interpersonal therapy, supportive therapy, and family therapy. Combined psychotherapy and pharmacotherapy are most common.
- Resident caseloads and patient contact hours per week vary depending on the particular combination of other rotations they are on at a given time. The clinical activity includes patients seen for assessment (including consultation and second opinions) only, while the majority receives ongoing treatment. Ongoing treatment includes some cases receiving pharmacotherapy alone, but the majority receives combined psychopharmacotherapy and psychotherapy. Each resident will have one or more family therapy cases, and residents are strongly encouraged to actively collaborate with other providers, including attending off-site care planning meetings at schools or other agencies where patients may also be receiving care.
- All residents have one hour of weekly individual supervision related to Clinic activity, in addition to required clinic-based group supervision following every patient visit. Second year residents have two hours of individual supervision in addition to the clinic-based group supervision. Additional supervision is readily available by request or when remediation is necessary to meet core competency expectations.
- The outpatient clinic is central to providing clinical opportunities which substantially address nearly every required educational goal including patient evaluations, range of diagnoses, age, demographics and treatment modalities. There are frequent opportunities for collaboration with pediatrics, schools, legal and community colleagues, exposure to psychological testing, pediatric neurology, psychiatric emergencies and care of acute seriously emotionally disturbed children.
- Clinical faculty supervisors are experienced in assessment, psychotherapy, behavior therapy, family therapy, and pharmacotherapy.
(OHSU) (Institution 1.1b)
- Required four-month rotation in which first-year residents spend one half-day per week (10% time).
- Faculty consists of three pediatric neurologists, Thomas Koch, M.D. , Amy Kao, M.D. And Colin Roberts, M.D. Specific didactic teaching occurs regarding clinical history taking, the neurological examination, common neurological conditions, EEGs, imaging methods and the pharmacology of anti-epileptic medications.
- The central teaching premise of this service is to learn pediatric neurology by doing it. The resident spends a half day each week attending a pediatric neurology clinic. The major learning occurs in the context of a broad range of clinical cases from birth to age 17 under the supervision of a staff neurologist.
- On this rotation the resident will see outpatients with a broad mix of ages, SES, ethnicity similar to that in the psychiatric outpatient clinic. Fellows co evaluate outpatient and inpatient consults with a variety of neurologic problems including epilepsy, headache, cerebral palsy, neuromuscular disorders, neurometabolic and genetic diseases. Care will be provided at Doernbecher Children’s Hospital in the Neurology specialty clinic. Residents will become familiar with the interpretation of EEG and neuroimaging studies, especially MRI.
- The resident participates in the care of approximately three to four cases each clinic day. The resident initially observes the faculty neurologist before assuming more responsibility for a case. The resident is responsible for writing or dictating all reports with referring physicians as needed.
- On-site supervision is provided by the faculty pediatric neurologist daily with each case in both group and individual formats
- This rotations fully meets educational goals related to neurology and adds to the experience of collaboration and consultation with other professionals
- Because the neurology clinic is next door, case based bi-directional collaboration and consultation occurs throughout fellows two year training.
OHSU Child Development and Rehabilitation Center
(CDRC) (OHSU) (Institution 1.1c)
- Required four-month rotation in the second year, three out of four weeks monthly. Residents alternate days at CDRC with Center for Continuous improvement institution 1.6 so the total time is 20%.
- Faculty consists of three full-time OHSU faculty developmental behavioral pediatricians: Dr. Peter Blasco, Dr. Robin McCoy, and Dr. Rita Panoscha. The resident primarily works with Dr. Blasco and Dr. McCoy, occasionally with Dr. Panoscha. The resident has contact with a core team consisting of a developmental pediatrician, a psychologist, a social worker, a speech pathologist, a special education teacher, and an occupational therapist.
- Residents participate in interdisciplinary evaluations of children with developmental disabilities and their families. The resident, along with staff and students from three to six disciplines, observes all aspects of the evaluation through one-way mirrors, conducts the psychiatric interview, conducts a cursory physical examination and full neuro-developmental evaluation under the guidance of the faculty attending, and reports the findings of the child and family assessment during the team conference dealing with assessment and treatment planning and implementation. The resident occasionally may become the ongoing therapist for selected cases, which can be referred to the OHSU Child Psychiatry Clinic.
- The CDRC population in a recent survey was roughly equal in males and females; 91% white; a range of ages with the majority distributed fairly evenly between 0-1, 6-11, and 12-17. Primary diagnoses include all disabilities (e.g. , 6.7% cerebral palsy, 6.7% communication disorders, 1.5% hearing impairment, 1.2% learning disability, 14% genetic disorders, 0.57% autism). The resident primarily sees children with complex behavioral, social and constitutional problems with multiple diagnoses.
- The resident caseload primarily includes the children who are seen for the two-thirds day interdisciplinary team evaluations and selected follow-up with cases seen previously. The resident will see 12-16 complex children and their families during the rotation. The resident participates in the Child Development Clinic, directed by Dr. Blasco, an interdisciplinary clinic encompassing school-aged children with learning and behavioral problems. Residents also have the opportunity to participate in the Autism Clinic directed by Dr. McCoy and involving preschool and school age children with autism spectrum behavior problems and developmental deficits, usually language. The resident serves as case coordinator for several cases and dictates the summary including results of all the evaluations.
- In-room supervision is provided by the faculty pediatricians on a one-to-one basis. The faculty attending also participates in the clinical conferences and directly observes the resident’s work and gives feedback after the clinical interview.
- This rotation allows for meeting educational goals in the following areas within the age and diagnostic range as described above: Patient evaluations, early childhood / developmental diagnoses, broad age and demographic population, treatment modalities (including Occupational and Speech therapies), onsite collaboration with social work, occupational therapists, speech therapists developmental pediatricians and referring clinicians and agencies and direct observation of psychological testing, neurological examination. The fellow has the opportunity to provide consultation to pediatricians, schools and other community agencies.
- This rotation is particularly strong in the area of young child developmental evaluation and the primary exposure to moderately to severely affected autistic children.
Pediatric Consultation-Liaison Service
(OHSU) (Institution 1.1d)
- Required four month, 30%, required rotation in the second year. Consultation requests are received from Doernbecher Children’s Hospital (medical/surgical, hematology-oncology, and intensive care units) and OHSU Pediatric Emergency Department; this experience also includes some urgent outpatient consultations requested by Pediatrics.
- The service is staffed by the full-time Director of the Division of Child and Adolescent Psychiatry, who also functions as the Director of the Consultation-Liaison Service with three other board certified child psychiatrist faculty members.
- Residents spend an average of 3-4 hours per consultation, much of it away from the bedside, integrating data from various sources, communicating with the family, medical, and nursing staff, attending case conferences around specific patients, and pediatric case conferences that function as teaching rounds for pediatrics house staff.
- Past surveys have shown that yearly a total of 165 patients are seen on the service. Ages ranged from 1 to 19 years. Ten children were 5 years of age or younger, thirty-six were 6 through 12 years old, and the remainder were in their teens. Diagnoses varied widely but were predominantly adjustment disorders, conversion disorders, depressive disorders (including suicidality), disruptive behavior disorders, eating disorders, and feeding disorders. When treatment was provided in addition to the initial assessment it was either supportive therapy for the child and/or parent or short-term psychotherapy for the child; pharmacotherapy is also recommended as indicated, usually for anxiety, depression, or psychotic symptoms.
- The number of consultations performed on a weekly basis by each resident ranges from zero to four or five, but generally averages slightly more than three per week. Consultations typically involve a discussion with the attending and/or resident physician, meetings with other relevant ward staff such as the patient’s nurse or child life worker, and a meeting with the child and his/her parent(s)/guardian(s).
- Individual supervision with Director of the Pediatric Consultation-Liaison Service or with the attending physician covering the consult service on a given day occurs after the completion of each consult. The resident receives bedside teaching through his/her interactions with the attending physician around issues of each patient’s clinical diagnosis and treatment. The resident has the opportunity to observe the attending physician evaluate patients on the Consultation service. As the rotation progresses the resident takes increasing responsibility as the primary consultant.
- This rotation allows for educational opportunities in the following areas:
- Patient evaluations, full spectrum of diagnoses, age and demographics, brief therapies and crisis intervention, collaboration with multidisciplinary teams, pediatric neurology, psychiatric emergencies, acutely seriously emotionally disturbed children and consultation with pediatrics.
- Special emphasis is placed on the importance of a very timely response to all consultation requests and on rapid written and verbal feedback to the attending and/ or pediatric house staff requesting the consult. At least one clinical skills competency exam is documented on this rotation for each fellow.
Pediatric Sleep Medicine
(OHSU) (Institution 1.1e)
- Required four-month rotation in which second-year residents spend one half-day per week (10% time).
- Faculty consists of two pediatric sleep specialists, Kyle Johnson, M.D. , and, M. Holger Link M.D. Dr. Johnson is a child and adolescent psychiatrist and Dr. Link is a pediatric pulmonologist. The child and adolescent psychiatry fellows will work with Dr. Johnson unless unavailable.
- Specific didactic teaching occurs regarding the taking of a sleep history, reasons for referral to a pediatric sleep clinic, common sleep problems in children and adolescents and treatments including cognitive behavioral interventions and pharmacotherapy. Additionally, fellows will be introduced to polysomnography.
- The central purpose of this rotation is to learn about sleep in children and adolescents including normal sleep physiology and how it changes over development and sleep pathology. The child psychiatry fellow will spend one half day each week in the Doernbecher Children’s Hospital Sleep Medicine Clinic seeing patients with Dr. Johnson. Initially, they will observe Dr. Johnson taking a sleep history and conducting a physical examination on several cases, and then they will take the history and conduct the exams on subsequent cases with presentation of the cases to Dr. Johnson. Teaching will be done in the context of evaluating child and adolescent patients in the clinic and supplemented by directed reading. On this rotation, the fellows will see patients with various sleep problems including behavioral insomnia, primary insomnia, obstructive sleep apnea, parasomnias such as sleep terrors and sleep walking, narcolepsy, and circadian rhythm sleep disorders. Fellows will become familiar with the interpretation of polysomnography.
- The resident participates in the care of approximately three to four cases each clinic day including new referrals and follow-up patients. The fellow is responsible for dictating notes on patients seen which will be forwarded to referring physicians.
- On-site supervision is provided by Dr. Johnson, a child and adolescent psychiatrist and sleep specialist.
- Educational Goals met by this rotation: Comprehensive patient evaluations, diagnostic clarification, wide age and demographic range psychopharmacology, collaboration with sleep clinicians, pediatric neurology and consultation with pediatrics.
- Unique experience for residents in comprehensive diagnostic clarification in the sleep medicine environment.
Child and Adolescent Inpatient Rotation
(Providence Hospital) (Institution 1.2)
- Required four-month rotation during the first year and requiring 50% of the resident’s time.
- The teaching faculty consists of four clinical faculty child psychiatrists. Dr. Eugene Borkan, one of the clinical faculty child psychiatrists, directs the Providence program and coordinates the rotation. There are five licensed clinical social workers who provide consultation to the residents regarding family assessment and placement issues.
- Educational activities for the residents include: direct individual supervision with each attending on cases and daily team rounds on patients admitted.
- Residents see patients ranging in age from 3 to 17 years. There is a roughly 50:50 split between male and female patients assigned. The ethnic/cultural mix directly reflects the ethnic makeup of Oregon, with the majority of patients being Caucasian; other ethnic groups seen include African Americans, Asian Americans, Hispanics and American Indians. Thirty-five percent of the patients admitted to Providence have primary diagnoses of mood disorder of some type. Another 35% of admitted patients have a primary disruptive disorder diagnosis. About 20% of patients have a primary psychotic disorder diagnosis. The other 10% of patients have a variety of diagnoses, including eating disorders, severe OCD, organic disorders or other developmental disabilities including patients with mental retardation and autism/PDD. Treatment modalities include individual supportive, CBT, collaborative problem solving approaches, group psychotherapy, family therapy and pharmacotherapy.
- The average caseload for the residents is 3-4 patients on any given day. Case assignments are made with the following guidelines: keeping a balance between sex, age and types of diagnoses; keeping caseloads between 3-4 patients; and an eye toward unusual cases. There is also an effort to have the resident co-admit with each of the attending child psychiatrists. The residents are assigned cases at the time of the patient’s admission. The serve as the primary physician for patients and follow them from admission to discharge. Residents on average admit 50-60 patients during their rotation. Clinical activities include: initial evaluations, individual interviews with parents and patients, participation in family assessment and intervention meetings, the development of milieu treatment plans, leading multidisciplinary treatment team discussions of their patients, administration of psychotropic medications, working with managed care insurance issues, collaborating with social workers and outside services such as child protective services, schools, child welfare agencies, corrections authorities and community clinicians. The on-call requirement is one weekend a month, with one of the faculty child psychiatrists. On-call residents are in charge of patients entering the service through the triage service, emergency room or pediatric service.
- Residents have attending backup 24 hours a day, and do daily rounds with an attending physician while on weekend call. Residents have direct individual supervision at least one hour a week, in addition to daily informal check-ins with attending physicians and participation in morning rounds.
- This rotation is a core experience fulfilling a number of educational requirements in an acute setting:
- Patient evaluations, range of diagnoses, age, demographics and treatment modalities. There are frequent opportunities for collaboration with diverse members of the treatment team, pediatrics, schools, legal and community colleagues, exposure to psychological testing, pediatric neurology, psychiatric emergencies and care of acute seriously emotionally disturbed children. A wide range of individuals seek consultation from the inpatient team at discharge.
- This is an extraordinarily stable unit with a 30+ year medical director and clinical director and many staff with over 20 years of experience. At least one clinical skills competency exam is documented on this rotation for each fellow.
Children’s Psychiatric Day Treament Center
(Lifeworks NW) (Institution 1.3a)
- This is a required experience in the first year of child training. Each fellow participates on the rotation two days per week for four months.
- Faculty staff consists of the Director of the Child and Adolescent Psychiatry Division, who functions as Child Psychiatry Consultant to the Young Child Day Treatment Program (YCDTP)
- The educational goal of the rotation is to provide the trainee with the knowledge, skills and attitudes to provide competent care for severely disturbed preschool and early school age children and to acquire hands-on knowledge of the description, etiology and treatment of disturbed young children with severe behavioral and psychological impairments. The rotation also supplements the resident’s knowledge of normal development in 3-5 year old children and illustrates how normal developmental tasks are disrupted by psychiatric disturbance in young children. Each resident conducts comprehensive assessments of severely disturbed young children with complex psychological, medical/constitutional factors and environmental factors. They gain experience treating severely disturbed young children in a psychiatric day treatment therapeutic milieu along with other mental health professionals employing a variety of treatment modalities, including behavior modification, collaborative problem solving, group therapy, family therapy, psychopharmacology, and individual psychotherapy. In addition to the on-site supervision provided by the consultant, their work is also directly supervised by the program's clinical director, an experienced LCSW.
- The majority of the patients are of lower Socioeconomic status (SES), although approximately 1/4 to 1/3 are of middle or upper-middle class origin. Gender distribution is balanced between males and females, and patients range in age from 3 to 10. Their ethnic/cultural mix generally parallel the population of Portland and surrounding areas, with the vast majority being Caucasian, along with smaller percentages of Hispanic, Asian, African American and Native American patients. Patients' diagnoses typically include Attention-deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Major Depressive Disorder, Separation Anxiety Disorder, Post-traumatic Stress Disorder, Pervasive Developmental Disorder, and Reactive Attachment Disorder. The program's primary therapeutic approach is based on Collaborative Problem Solving. In addition, the program utilizes behavior modification, collaborative problem solving, group therapy, family therapy, individual psychotherapy, and psychopharmacology as treatment modalities.
- Residents are typically responsible for all patients in one of three classrooms in the YCDTP. A classroom normally contains eight patients ranging in age from 3 to 10 years of age.
- The Consultant provides on-site clinical supervision on an individual basis at least once a week. He is also available for supervision within the division or on call as the need arises. The Consultant is on-site six hours per week during one of the two days that the fellow is present.
- The focus is on the preschool age group and contributes substantially to educational goals in the following categories for this age group: patient evaluations, diagnoses, longer term treatment modalities including group therapy, milieu therapies and play therapy collaboration with a diverse treatment team, exposure to psychological testing and consultation to schools and community care providers.
- The fellows’ time in the milieu allows observation of experienced staff who demonstrates effective ways to interact with highly stressed, inflexible and explosive children. At least one clinical skills competency exam is documented on this rotation for each fellow.
(Lifeworks NW) (Institution 1.3b)
- LifeWorks Northwest (LWNW) child and adolescent psychiatry rotation is an elective rotation offered during the second-year of fellowship. On the LWNW rotation fellows are a part of the Early Assessment and Support Alliance team for Washington County, an evidence-based treatment program which aims to identify and provide wraparound psychosocial support for teens and young adults who are suffering schizophrenia-spectrum illness. (10%TIME)
- Fellows work directly with an OHSU faculty child and adolescent psychiatrist, but are also expected to work with/see patients and families with two social workers, an occupational therapist, and a housing/employment specialist.
- Fellows are expected to:
- Participate in the weekly multidisciplinary team rounds/clinical meeting
- Provide at least one presentation to the multidisciplinary team on topics related to early psychosis intervention
- Observe and provide evaluations of new patients referred to the LWNW/EASA, reviewing the cases with their supervisor and presenting their report to the multidisciplinary team.
- Review readings relevant to early assessment and intervention of schizophrenia spectrum illnesses
- Review all cases with the OHSU faculty supervisor who is on site and sees many of the cases with the fellow.
- Develop and practice skills in cognitive behavioral therapy for schizophrenia.
- Participate in conferences; the EASA program and it’s sibling programs (those in other counties) have regular meetings on early psychosis intervention; fellows are encouraged join these if possible.
- Patients referred to/participating in the LWNW EASA program are age 15-25, of wide socioeconomic and ethnic backgrounds. Most patients are young men, but there are also women in the program. The chief disorders patients within the EASA program suffer include: schizophrenia, bipolar disorder entailing mania with psychotic features, psychosis-related to substance abuse disorders, post-traumatic stress disorder, and brief psychotic disorder.
- Caseloads vary as the program is small (usually 20-25 patients) and fellows follow new patients/families as they are screened and accepted into the program. We aim for 3-4 patients to be directly cared for by the child and adolescent psychiatry fellow.
- Supervision is 1:1 with the OHSU faculty member and occurs weekly; much of the time is spent directly seeing patients/families and participating in meetings in which the faculty member is present.
- This rotation provides educational opportunities which meet educational requirements in the following categories in the context of narrower diagnostic and age group:
- Patient evaluations, range of diagnoses, age, demographics and treatment modalities.
- There are frequent opportunities for collaboration, exposure to psychological testing, pediatric neurology, psychiatric emergencies and care of acute seriously emotionally disturbed children.
- Supplementary Information: Collaboration. The Early Assessment and Support Alliance is a program aimed at supporting individuals with new-onset schizophrenia-spectrum symptoms and their families. This rotation offers fellows a unique multidisciplinary experience, as they are able to observe and collaborate with social workers, a nurse, an occupational therapist, a housing specialist, and an employment/academic assistant—all of whom work with EASA patients and families outside the office setting.
Oregon Youth Authority
(Maclaren Correctional Facility) (Institution 1.4)
- Required four-month rotation during the second year, requiring one half-day per week (10% time).
- Fellows work directly with Dr. Joshua Dow, a Board Eligible Child Psychiatrist. They also periodically consult with William Sack, M.D. , emeritus professor and past division director. . The resident also has contact with the staff pediatrician, nurses, and masters level mental health therapists in the clinic.
- Residents meet weekly with Dr. Dow to learn about evaluation and treatment of psychiatric disorders in delinquent youth and discuss legal issues involving their adjudication and disposition.
- There are approximately 400 students at MacLaren, all of who are adjudicated and in the custody of the Oregon Youth Authority. Youths at MacLaren are exclusively male; primarily adolescents between 14 and 20, but some are young adults under 25 years. Sixty percent of the population has problems with substance abuse and 80% carry a primary diagnosis of conduct disorder. About 40% of the youth are on psychotropic medications; the majority of these have problems with attention deficit hyperactivity disorder or affective disorders, and about 40% of the youth have a diagnosis of posttraumatic stress disorder. In addition, 5% of the youth have a diagnosis of functional psychosis. Perhaps 50% of the youth now housed at MacLaren have been adjudicated for sex offenses. Treatment is primarily of a cognitive behavioral nature. There is an ongoing cognitive therapy group for depressed youths as well as grief and loss groups, a victims group and violent offenders groups. There currently are two ongoing inpatient sex offender cottages, an anger management cottage, a pre-treatment group for those entering into “boot camp” experiences and specific programs designed to help those youths with major mental illnesses.
- Residents follow approximately 25-30 cases throughout this rotation. They also complete assessments and take part in a group therapy with violent youth offenders one hour per week. Residents are involved in ongoing communication with mental health professionals, treatment managers and clinic staff.
- Individual supervision with Dr. Dow for 30-60 minutes weekly and Dr. Sack monthly for one hour.
- Educational requirements addressed at this site.
- Patient evaluations, range of diagnoses, age, demographics and treatment modalities. There are frequent opportunities for collaboration with diverse members of the treatment team, pediatrics, schools, legal and community colleagues, exposure to psychological testing, pediatric neurology, psychiatric emergencies and care of acute seriously emotionally disturbed children. This is the primary site fulfilling the legal educational requirement.
- There is an opportunity for administrative consultation with directors of Oregon Youth Authority in the context of monthly staff meetings and informal luncheons.
Christie Care Residential Treatment Programs
- Required four-month rotation during the first year and requiring 60% of the resident’s time.
- The teaching faculty consists of three clinical faculty child psychiatrists, one clinical social worker, Kit Kryger, LCSW, and the Executive Director of the Christie program, Lynne Saxton. Dr. John Deeney, one of the clinical faculty child psychiatrists, has been the Medical Director for the program and coordinates the rotation. The other child psychiatry faculty includes Dr. Michael Franz and Dr. Karan Randhava. The residents interact with social workers and masters prepared counselors in all the three treatment cottages through which they rotate concerning a variety of milieu therapy issues, family interventions, planning for disposition, and interfacing with community agencies involved in the cases they follow.
- Educational activities for the residents include: direct individual supervision with each attending on assigned cases and daily multidisciplinary team rounds on the attendings’ patients; and educational meetings with the Clinical Director and the Executive Director on program and systems issues. Residents have the opportunity to participate in a therapy group with a masters prepared counselor, and each resident has the opportunity to run a group by him/herself with faculty supervision.
- ChristieCare residential programs serve youth with severe psychiatric disorders that cannot be served in less restrictive levels of care. Residents rotate through three of Christie’s programs, representing a continuum of severity of problems. These include 1) Subacute Program serving acute patients requiring a high level of security, individualized planning, comprehensive assessment, and disposition collaboration with community agencies; 2) Willamette Cottage for the most severe psychiatric disorders requiring high levels of security and short-medium term residential treatment; and 3) the Cedar Bough Program which serves primarily Native American youth in a somewhat less secure residential environment with emphasis on medium term treatment and careful community reintegration following the residential experience. Residents also have an opportunity to participate in program elements that provide community-based intensive wraparound services for enrolled youth. Youth at Christie range in age from 6-18 years. There is a roughly even split between male and female patients assigned. The ethnic/cultural mix reflects the ethnic makeup of Oregon, with the majority of patients being Caucasian; other ethnic groups seen include Hispanics, Native Americans, African Americans and Asian Americans. The most prevalent diagnoses are mood disorders, disruptive behavior disorders (including Attention-Deficit Hyperactivity Disorder and Conduct Disorder), anxiety disorders (especially Posttraumatic Stress Disorder), autism spectrum disorders and substance use disorders.
- The average caseload for the residents is five patients on any given day. Case assignments are made so that caseloads are balanced with respect to gender, age, psychopathology and severity of illness. Residents have patients in each of the cottages in order work with all the attendings. The residents serve as the primary physician for patients and follow them for the duration of the rotation. The average number of patients followed is seven or eight. The average length of stay in Christie programs varies. Christie clients in the Subacute Program may stay from 7-30 days, while clients in the other residential program stay generally between two and seven months. The residents’ clinical activities include: initial evaluations, individual interviews with parents and patients, participation in family assessment and intervention meetings, the development of milieu treatment plans, leading multidisciplinary treatment team discussions of their patients, prescription and monitoring of psychotropic medications, working with managed care insurance issues, collaborating with social workers and outside services such as child protective services, schools, child welfare agencies, corrections authorities, and community clinicians. An additional unique and valuable feature of this rotation is that, owing to the longer length of stay than in an inpatient hospital, residents do weekly individual psychotherapy and sometimes family therapy with each of their assigned cases.
- Residents have direct individual supervision at least one hour a week with Dr. Deeney, Rotation Director, and on average one hour a week is spent in case related supervision with each of the other attendings.
- This rotation provides substantial opportunities similar to the hospital rotation (1.2) but with slightly less acuity and longer length of stay. Patient evaluations, range of diagnoses, age, demographics and treatment modalities. There are frequent opportunities for collaboration with diverse members of the treatment team, pediatrics, schools, legal and community colleagues, exposure to psychological testing, psychiatric emergencies and care of acute seriously emotionally disturbed children. A wide range of individuals seek consultation from the treatment team at discharge.
- The residents meet occasionally with Ms. Lynne Saxon, ChristieCare’s Executive Director, for education around administrative issues including Christie’s program development, to address the changing needs and requirements of the community mental health system in Oregon. They will usually have the opportunity to attend at least one state level meeting with her in which they learn more about the state mental health system.
Center for Continuous Improvement
- Required 2nd year rotation once a month for four months (alternating with CDRC Inst.1.1c for a total time of 20%)
- Faculty staffing: One part-time child/adolescent psychiatrist (equivalent of 2- 3 days a month of clinical/paperwork services)
- Educational activities: Fellow is involved in observation/participation/consultation while shadowing psychiatrist during psychiatric assessments, med management follow-up appointments, team meetings, team training efforts, phone conferences, group home visits, and brief therapy interventions provided by psychiatrist (supportive, motivational enhancement, psychoeducational, skills-promoting, lifestyle-modifying, CBT, etc) as needed. Fellow may also provide support to client and team with problem-focused literature review, independent clinical service procedures (Mental Status Exam; Abnormal Involuntary Movement Scale etc), liaison with allied partners primary care physician, Department of Human Services and second opinions with respect to target symptoms, differential diagnosis, formulation, behavioral consultation, psychopharmacologic interventions, and/or program design of psychiatric consultation service. Fellows provide an in-service training to the service team on a relevant psychiatric topic.
- Clinical population characteristics: ages 8 - late 40’s (historically); 80-90 % are under 18 yo; 15 - 25 clients (historically) receive in-house psychiatric services; 90-100 % have developmental disabilities (mental retardation, Borderline Intellectual Functioning; Pervasive Developmental Disorder; Cerebral Palsy; language/speech deficits; sensory-integration deficits; learning disabilities; drug- and/or alcohol-related neurodevelopmental delays); approximately 90-100 % (of those followed by the psychiatrist) have functionally-impairing psychiatric target symptoms (disruptive-spectrum, mood-spectrum, anxiety-spectrum, psychotic-spectrum) and/or clearly established psychiatric disorders involving same types of symptoms; multiple co-morbidities and/or rule-outs are the norm; male to female ratio is about 60:40; vast majority have history of multiple risk factors that include: child maltreatment (neglect; abandonment; sexual abuse; physical abuse; emotional abuse; domestic violence; inadequate supervision; inadequate nurturance; fragmented family supports over time); exposure to drug/alcohol abuse in home/street environments; homelessness; divorce; separation from family; family history of psychopathology, developmental disabilities, incarceration, substance abuse. DHS involvement; legal system involvement; multiple unsuccessful foster placements; past psychiatric hospitalizations/residential placements; inadequate social supports; most clients have history of functional impairments in academic, social, family-based, self-care, lifestyle/recreational and/or future-orientation domains; almost all have history of past/current psychiatric medication treatments and most are admitted to CCI while on complex psychiatric med regimens; more than 70 % are obese or overweight; almost all are receiving or have received OHP coverage; an estimated 75% or more have family of origin that would be considered in the lowest SES, with about 25 % from a broad middle class background; estimated racial/ethnic/cultural mix: 50 % Caucasian; 10 % African American; 10-15 % Hispanic; 10- 15 % native American; 10 % Asian; about 50% having mixed heritage. Treatments include: psychiatric medication; school accommodations; behavioral support plan; Applied Behavioral Analysis-type interventions; skills-building interventions; counseling in outside agency (individual; family; group); brief therapy interventions as part of psychiatric services (see above).
- Average case loads for psychiatrist- 15 to 25 (currently around 15, due to contract variations); average independent case load for fellow - none.
- Supervision: monthly for up to 8 hours; mostly in team setting, +/- individual; phone/email communications, as needed.
- Multiple required patient care experiences may be addressed in this rotation but the focus is on exposure to evaluation and treatment of severely mentally ill and developmentally delayed population.
Tillamook County Mental Health Clinic
- This rotation is an elective available during the second year of child and adolescent psychiatry training. The clinical experience is offered at Tillamook Family Counseling Center, (TFCC) the community mental health center for Tillamook County, a rural area on the Oregon coast. This full day elective occurs on the 1st and 3rd Friday of the month over a four month period (10% time)
- The fellow works with the OHSU Division Director, who participates in and supervises the rotation on-site.
- The educational experience consists of 1-2 hours of case supervision during each clinic visit.
- The patients seen at TFCC are equally males and females, of primarily Caucasian ethnicity, but with some Latino patients in proportion to the residents of the county. The SES of most patients’s seen ranges from poverty-level to a lower middle and a few middle class families. Diagnoses vary widely, ranging from autism and Asperger's, to ADHD and other behavior disorders, to Major Depressive and Bipolar Affective Disorders, to Anxiety Disorders, PTSD, and Obsessive Compulsive Disorders. Some of the patients seen also have substance abuse disorders. The treatment provided is primarily long-term psychopharmacologic management.
- Residents see an average of 8 to 10 patients during each visit. There are one or two new evaluations each visit, along with 7 to 9 medication management sessions. A resident's total case load is approximately 20 patients.
- Individual case supervision occurs over the lunch hour and during the 1 and 1/2 hour drive back to Portland.
- This rotation is a typical outpatient mental health clinic, but the population is from a heavily rural setting.
- Patient evaluations, range of diagnoses, age, demographics and treatment modalities, collaboration with pediatrics, schools, legal and community colleagues, exposure to psychological testing, psychiatric emergencies and care of acute seriously emotionally disturbed children.
- H. This rotation provides residents with a rural child psychiatry experience.
Portland Public Schools Rotation
(Varying sites within Portland Public School District) (Institution 1.8)
- Required four-month rotation in which second year residents spend one half day per week (10% time)
- Faculty consists of the director of psychological services at Portland Public Schools, Marlaine Jensen, PhD and Ajit Jetmalani, M.D.
- Following didactic discussions of the school system, disability law, range of services and personnel, the fellows accompany school psychologists in the following areas; normal grade school middle school and high school environments as well as self contained classrooms geared toward support of children with learning issues behavioral issues, autism and other developmental disabilities. They will understand the expectations in classrooms and the culture of the school and observe the development of an Individual Education Plans (IEP) in a team meeting.
- This rotation allows for exposure to the full spectrum of ages, ethnicity, culture and SES in the school age population (preschool to HS). The expectation is that the fellow will see normal children in the school environment as well as children with behavioral and emotional struggles. They will observe but not implement educational and behavioral structure. They do not primarily interface with psychiatric settings and conditions as this is addressed on other rotations.
- Fellows will not carry a case load as this is an observational and didactic experience.
- As clinical care is not provided, clinical supervision will not occur but daily experience will be guided by a school psychologist at various sites. Dr. Jetmalani provides consultation as needed to Dr. Jensen and the fellow.
- This rotation provides opportunities of observation of normally developing children and collaboration and consultation with school personnel.
- This rotation is augmented by the requirement for fellows to attend an Individual Education Planning (IEP) meeting for one of their outpatients annually.
Depaul Youth Services
- This is a required second rotation for half a day a week (10% time).
- The medical director Stephan Mandler, D.O. is a board certified child and adolescent psychiatrist. The fellow will also work with a psychiatric nurse practitioner but all work is directly reviewed and cosigned by Dr. Mandler.
- Fellows will receive didactic and supervisory education from the clinical faculty as well as learn from observation of various treatment modalities.
- This is a broad mix of adolescents over the age of 12. The mix is equal male and female with a wide range of socioeconomic cultural and ethnic backgrounds.
- The fellows will not have primary responsibility for patient care but will participate in evaluations, individual, milieu and group treatment modalities including AA (Alcoholics Anonymous) oriented 12-step approaches.
- The fellow will receive individual weekly supervision for one hour.
- This rotation is primarily focused on drug and alcohol evaluation and treatment educational requirements, although the patients have dual diagnoses and many other educational requirements are addressed related to collaboration consultation diagnosis and group therapy modalities.
- This is the only residential dual diagnosis chemical dependency program in town with a full continuum of care.
Fruit and Flower Day Care
- This is a required rotation for first and second year fellows. They spend two hours once a month for 5 months.
- The faculty includes Drs. McKelvey and Jetmalani with onsite supervision by the director of the day care, Judi Gilles.
- The educational experience is the opportunity to observe children in a normal day care setting. Fellows are encouraged to apply didactic learning about normal development and social behavior in this observational experience and encouraged to discuss observations in development seminar with Dr. McKelvey.
- The children are 3 months to 5 years of age
- No case load
- No clinical care is rendered so no supervision is provided other than logistics by Ms. Gilles and discussion in Development seminar.
- Primary Educational Goal is observation of normal development age infancy to 5.
- This is a 100 year old day care with a highly developed staff and leadership providing fellows the opportunity to observe the best possible group day care setting for comparison.