Inpatient and Partial Hospital Care
In Year 2, residents devote approximately 30 hours per week for eight months toward inpatient, acute residential and partial hospital care at McLean and Franciscan Children’s Hospitals. In recent years, there have been changes in hospital-based evaluations and treatment nationwide. Under the leadership of Joseph Gold, M.D., Clinical Director of the Child and Adolescent Program at McLean, the program has made numerous modifications in its health care system to provide the highest quality of care for its youth and families. Guiding principles in implementing these changes include utilization of a strong multidisciplinary team; provision of a continuum of care involving close collaborations between inpatient and other levels of care; integration of education and treatment services by creating multiple special education schools; and public advocacy and development of close working relationships with community public sector agencies, primary care pediatricians and health maintenance organizations. The essence of care is continuity of treatment. Thus, the goal of the hospital care rotation is for the resident to learn principles of evaluation, multimodal treatment and disposition planning in the context of a continuous care plan. All of these principles and skills are taught through the highly supervised hospital care rotations.

The judicious use of the McLean inpatient facilities with step-down, and close coordination with other levels of care, facilitates short-term treatment plans that otherwise could not have been formulated and implemented in the high-risk population that McLean serves.

Hospitalization makes it possible to diagnose and treat children and families when other resources have failed. Hospitalization permits the unit to collect essential diagnostic and treatment data through detailed observations of patient and family. Hospitalization provides for the child, perhaps for the first time, a structured, protective, holding and limiting social and educational environment. For others, an intensive and expert “second opinion” is provided after previous community-based services proved unable to contain the child safely. Hospitalization is critical when the behavior or feelings of the child or family members become unmanageable and present a threat to the safety
of persons or property in family and community.

While on their four-month, 30-hour/week inpatient rotation at Franciscan Children’s Hospital, second-year residents provide intensive evaluation and treatment planning for school-age children, adolescents and their families. At Franciscan’s, residents provide coverage for admissions during the day on a rotating basis. They follow cases as providers of comprehensive treatment for children, adolescents and families, along with members of the multidisciplinary team and under the supervision of attending staff child psychiatrists, Drs. Thrassos Calligas and Andrew Stromberg, who each have over twenty years of inpatient child psychiatry experience. As the physician, the resident is responsible and accountable for the planning, multimodal treatment, disposition and aftercare of his or her patients. The residents participate in the multidisciplinary team, which synthesizes the psychiatric, pediatric/neurologic, psychoeducational and community resources. Treatment includes psychotherapy, pharmacotherapy, psychoeducation, family therapy, cognitive behavior therapy, group therapies, activity therapy and applied behavior analysis. In addition to child psychiatry attending supervision by the physician-in-charge (PIC) overseeing each case, residents have additional supervision from the inpatient unit for psychopharmacology, group therapy and behavior and cognitive therapy, as needed. The residents on the unit attend a weekly multidisciplinary case conference, daily rounds on all patients, community meetings and treatment review conferences. Residents also carry a small volume of cases that are admitted to a specialty track on the unit for youths with mental retardation and/or autistic spectrum disorders who are in acute psychiatric crisis.

Residents also spend 30 hours/week for four months in the McLean partial hospital and Acute Residential Treatment (ART) rotation. Dr. Michael Rater is the Medical Director, and Drs. Julie VanderFeenand and Dominique Vo are attending child psychiatrists. All three provide supervision for the residents. The ART and Partial Hospital Program offers an intensive treatment experience for adolescents who do not require inpatient hospitalization but need a more structured, in-depth form of treatment than is possible in an outpatient setting. The program treats moderately to severely disturbed adolescents diagnosed with a range of psychiatric disorders, including mood and anxiety disorders, severe character disorders, substance abuse and post-traumatic stress disorders. The mission of the program is to increase resilience and functioning within the family and community.

Participants in the partial hospital program follow a core schedule from 9 a.m. to 3 p.m., including individual, family and group psychotherapy. Participants have access to psychotherapy groups and activities that cover development of coping and social skills, anger management, substance abuse and relapse prevention. Wellness groups include arts and creative activities such as cooking, young men’s and young women’s issues and sports. Partial hospitalization is cost-effective and allows for a deliberate process of integration into the community.

Acute Residential Treatment (ART) is available to adolescents who require 24-hour care. This is an unlocked setting licensed by the Office for Child Care Services. The ART program is housed on the second floor of East House at McLean Hospital, with some of its daytime classrooms in the new, adjacent Academic Center. The 30 beds are divided into 12 short-term (ART) and 18 longer-term transitional care unit (TCU) beds. The latter are part of a unique collaboration with state agencies to serve teens in state custody who were “stuck” in hospitals for prolonged periods. The ART program is designed to accommodate patients who require relatively short courses of residential treatment. Many of these patients are involved in the substance abuse and relapse prevention program. Dialectical Behavioral Therapy (DBT) is a key component of these programs and is integrated across day program and residential components.

While in the partial hospital and acute residential rotation, residents will serve as psychiatrists in an intensive multidisciplinary milieu. They are assigned four patients at a time. As the physician responsible for the planning, treatment, disposition and aftercare of patients, the resident provides the synthesis of the psychiatric, pediatric/neurological, psychoeducational and community resources. Typically, residents co-lead two small psychotherapy groups a week, two specialty groups (e.g., trauma, substance abuse, psychodrama), and attend one community meeting per week. Residents are an integral part of the milieu team. They spend one hour per week in supervision with the Director, Michael Rater, M.D., one hour per week with the Program Director, Cynthia Kaplan, Ph.D., and one hour per week in individual psychopharmacology supervision with a Board-certified child psychiatrist. The residents attend a weekly case conference seminar, where expert consultants are invited in to discuss the treatment of one of the patients on the unit. There are staff meetings three times per week. There are also weekly team conferences and diagnostic review conferences in which residents participate.

Transitional care residential students are assigned to classrooms according to their clinical profile. Academic and therapeutic skills are taught in an integrated fashion.

Child and adolescent psychiatry residents and staff provide 24-hour on-call services, which include emergency and crisis consultation services. Night call duties are described in a section, “On-Call Duties: Years 1 and 2,” on page 62.

Residents may elect to follow one to two cases discharged to an aftercare facility on the McLean grounds, which might include the Partial Hospital Program, Arlington Day School, Pathways Academy, the new Eating Disorders Center, and Outpatient Clinic. They also may choose to follow discharged patients at MGH. Under supervision, this experience will provide the resident an opportunity to engage in a variety of aftercare settings and to participate in the child and family’s continuity of care.