Duke Child and Adolescent Residency Training Program
Duke University Hospital
Division of Child and Adolescent Psychiatry
Department of Psychiatry & Behavioral Sciences
(2004-2005 Academic Year)  

Vision
Mission
First Year of Training
Second Year of Training
Outpatient Child & Adolescent Clinical Services at Duke
Summary of Research Activities

Vision

Creating an exceptional educational environment is the heart of our vision for the Duke University Department of Psychiatry and Behavioral Sciences. Our mission is to provide lifelong educational activities for students, clinicians and investigators. We offer training at every level of professional development with the goal of training clinicians and investigators for the challenges of the twenty-first century. Trainees have opportunities to specialize, pursue unique interests and develop as leaders in community based practice and academia. The necessary close relationship between our training program and those in other medical specialties is highlighted by a joint medicine/psychiatry residency program and programs in medical psychology, which focus upon behavioral interventions for chronic medical illnesses. Training programs in the department take advantage of a broad range of clinical settings, research labs and technology-based teaching aids. The cornerstone of training, however, is mentorship of trainees by experienced clinicians and investigators, relationships that continue for many years beyond formal training.

Dan Blazer, M.D., Ph.D.,
Vice Chairman for Education

Mission

The mission of the Duke Child and Adolescent Residency Training Program is “To train leaders in clinical and academic psychiatry with an emphasis on integrating an evidenced-based approach to care for children and adolescents.” 

To fulfill this mission the Duke Child and Adolescent Residency Training Program has a cornerstone two year seminar in Evidenced Based Medicine which focuses on the practice of child psychiatry in the 21^st Century. Evidence-based Medicine (EBM) combines individual clinical expertise with the best available clinical evidence from systematic research in making decisions about the care of individual patients. Clinical expertise is the proficiency and judgment that individual clinicians acquire through knowledge, clinical experience, and practice. Clinical evidence comes from patient centered clinical research which investigates the accuracy and precision of diagnostic tests, the efficacy and safety of therapeutic regimes, and the reliability of prognostic indicators. The powerful combination of clinical expertise and documented evidence results in safer, more efficacious and accurate care of the patient. (DL Sackett, Evidence-based Medicine. How to Practice & Teach EBM, 2001.)

To provide the learning experience necessary for the development of clinical expertise in child and adolescent psychiatry there are a variety of clinical opportunities to provide a solid core experience while also encouraging each child psychiatry resident to develop his or her individual career interests. Many research opportunities are also readily available during the residency.

Our training sites include inpatient and outpatient child and adolescent services. The inpatient experience during the first year occurs at The Children’s Psychiatric Institute located at the nearby John Umstead Hospital . It is a public- sector; state hospital setting that serves primarily, but not exclusively, public sector patients and their families. The Children’s Services provides diagnostic and a treatment service for children age 5 years to 12 years. Adolescent Services provides diagnostic and treatment service for adolescents ages 13 years to 18 years.  The resident’s average caseload is four patients.  Responsibility for the resident’s cases is progressive with the expectation that residents will be able to function at the junior attending level by the end of their rotations. During the in-patient treatment experience, residents interact with and lead multidisciplinary treatment teams.

*Outpatient training occurs during both years. The first year residents go to The Duke Child & Family Study Center. It includes concurrent supervision behind a one way mirror of diagnostic assessments and treatment cases along with a Cognitive Behavioral Therapy case conference seminar. Also located at this site is the Family Studies Program where the first year resident does assessment and treatment of families behind a one way mirror. The second year outpatient clinical practice occurs at Duke and an affiliated community based outpatient practice. These clinical experiences have long term treatment experience with a caseload that encompasses a wide range of ages, diagnoses, and treatment approaches that include pharmacotherapy, cognitive behavioral child and family psychotherapy and psychodynamically oriented child psychotherapy.

Consultation-Liaison with Duke Pediatrics occurs in the second year in both pediatric inpatient and outpatient settings. The Consultation-Liaison (C-L) Service occurs on the in-patient pediatric medical/surgical units, at Duke University Hospital . The duration of the rotation is 6 months with case based consults rounds.

Elective time is available in the second year. Examples of clinical include the eating disorders program, an extended rotation at the Center for Child and Family Health learning about the evidence based treatments for P.T.S.D. in children, adolescents and families, consultation at a residential school based treatment program for severely emotionally disturbed youth, rotation at a therapeutic preschool program and pediatric specialty clinics. Research elective opportunities within the Division are expanding rapidly and residents may train in a variety of areas i.e. Developmental Epidemiology Program (Dr. Adrian Angold, Dr. Jane Costello, Dr. Helen Egger, Dr. John Fairbank), Anxiety and Affective Disorders: Program in Child Affective and Anxiety Disorders (Dr. John March, Dr. Karen Wells, and Dr. John Curry who have ongoing NIMH funded research with children with OCD, anxiety disorders and depression) , Service Effectiveness Research (Dr. Jeff Epstein), molecular genetics of neuropsychiatric disorders, etc.  Involvement and interface with the rest of the Department of Psychiatry greatly broadens research possibilities.  Residents are encouraged to develop their own research interests.  Post-residency research training positions are available.

On-call responsibilities include a one week (out of approximately four weeks) of supervisory telephone back-up to the ED social worker during the week and the on-call general residents in the emergency room during the week-end. The Emergency Department Consultation Service (ED) experience occurs across both years. Back-up concurrent supervision is provided by the on-call child division faculty by beeper.

A chief child psychiatry residency position is available. There are many opportunities for residents to teach medical students, or residents, and to interact with trainees from other disciplines.

The didactic core includes a two seminar series. Both are two years.  Basic Concepts covers normal development, psychopathology, and treatment. Evidence Based Medicine reviews the basic principles of evidence based medicine while covering the current research evidence for child psychiatry topics including developmental epidemiology, genetics of mental illness, diagnosis, and treatments- psychopharmacology and psychosocial treatments. Case conferences include the weekly child psychotherapy case conference, and monthly consultation-liaison case conference.

Regularly scheduled supervision with child psychiatry faculty occurs in all aspects of training.  Residents are evaluated by supervisory faculty at least semi-annually and are asked to evaluate the training program in writing as well.

Managed care and ethics issues are addressed at all levels of training.

First Year of Training

·         Inpatient Rotation

On inpatient services at the Children’s Psychiatric Institute, residents will perform complete diagnostic evaluations of the children, adolescents, parents and families entering the inpatient unit.  Residents will then be responsible for integrating the treatment plan based upon the results of the evaluation, and whenever possible, following the patient and family through the continuum-of-care programs.  Residents will be the team captains and responsible for psychotherapeutic and psychopharmacological treatment as well as working closely with the milieu programming. Residents will also participate when indicated in family and parent therapy as well as the group psychotherapy involving their patients.

Residents at the Children’s Psychiatric Institute will rotate for 6months each in these latency and adolescent units.

·         Diagnostic and Treatment Team – 2 hours/week/12 months at CPI (1^ST year)

Residents perform outpatient evaluations and short-term treatment with families, parents, children, and adolescents under supervision of the staff child psychiatrist team leader and the multi-disciplinary team faculty.  Collaboration with other community agencies including schools, courts, and social services is a vital treatment component.

·         Family Therapy – 3 hours/week (1^st year)

Residents will perform family therapy while being observed by supervisors and other residents.  The family therapy literature seminar will be 1 ½ hours/week over the 6 months.  The major theoretical schools of family therapy will be reviewed in this seminar.  Residents from Duke training program participated in the family therapy seminar during their general training.

·         Didactic Conferences –

·         Normal Child Observation –  

Residents carry out systematic observations of infants, children, and adolescents in infant care center, day care settings, kindergartens, elementary and junior high schools.  Group supervision is included in the four hours.

·         Outpatient Treatment of Families, Parents, Children, and Adolescents –

Residents conduct ongoing long-term outpatient child and adolescent psychotherapy, and family therapy with one hour/week of regularly scheduled supervision with a staff child psychiatrist.  Cases are carefully selected so that the resident can gain experience with a broad spectrum of psychopathology.  Medication management cases are included.

·         Child Psychotherapy Program –  (both years)

A child or adolescent is worked with in weekly sessions in Cognitive Behavioral Psychotherapy.  The resident also works with the parent as part of the treatment.  The case is presented to a supervisor in once/weekly case supervision

A long-term psychodynamic psychotherapy case starting in the first year is supervised weekly.

·         Developmental Disorders

Residents will evaluate and treat patients of varying ages with developmental disorders in multiple treatment settings, including inpatient, outpatient treatment and psychopharmacology clinic.  They will also observe these patients in multiple specialized treatment settings during their 2 years of training. 

·         Individual Supervision – 2 hours/week

Individual supervision of inpatient work is included in the inpatient block of time.

·         Administration –  (both years)

Child residents meet with one of the program directors at least quarterly; carting, paperwork, conference preparation and weekly clinical management meeting and policy and planning meeting weekly.

Second Year of Training 

·         School-Based  Consultation

The School-Based Consultation Service experience has duration of 12 months at 10% of the resident’s time and is required. The primary educational activity of the School-Based Consultation rotation is real-time, direct discussions with and supervision of residents engaged in consultation to participating public schools with self-contained, therapeutic special education classrooms.  The faculty supervisor is present via live and interactive videoconferencing.

·         Psychopharmacology Clinic –

Residents will initiate medications and follow selected cases of children and adolescents on psychotropics under supervision of child psychiatric psychopharmacologists.

·         Developmental Disorders

Residents will evaluate and treat patients of varying ages with developmental disorders in multiple treatment settings, including outpatient treatment and psychopharmacology clinic.  They will also observe these patients in multiple specialized treatment settings during their 2 years of training.

·         Didactic Conferences –

·         Pediatric Consultation –

Residents will provide consultation to and liaison with pediatricians for inpatient setting pediatric patients. They will provide 24 hour emergency consultative service to the pediatric services.  Consultations will be supervised by the service attending.

·         Outpatient treatment of families, parents, children, and adolescents –

Residents conduct ongoing long-term outpatient child and adolescent psychotherapy, parent therapy, and family therapy with one hour/week of regularly scheduled supervision with a staff child psychiatrist.  Cases are carefully selected so that the resident can gain experience with a broad spectrum of psychopathology.  Medication management cases are included.

·   Duke Outpatient Psychiatry Clinics
          Duke Child & Family Study Center   ·         Affiliated Clinic
          Crabtree Clinic

·         Subspecialty Programs – 4 hours/week / 3 months
·    Pediatric Neurology Rotation – 4 hours/week/3 months
Several specialty settings including: Autism Clinic, Behavioral Disorders Clinic, and General Pediatric Neurology Clinic.
·   Developmental Delay Clinic- 4 hours/week/ 3 months
·    Psychopharmacology Clinic – 4 hours/week/ 3months
·     Substance Abuse Rotation – 4 hours/week/3 months

·         Elective Tracks –

Towards the end of the first residency year, residents submit a written statement concerning their clinical, administrative, academic, and research interests and how these will be developed during the elective time in the second residency year.  The purpose of the elective rotations is to provide a further foundation for eventual professional career goals in child and adolescent psychiatry.  (Those wishing to enter a research, academic career track should initiate research activities in the first year of child psychiatry).

Any of the aforementioned services and rotations in the first year of residency can be resumed and/or expanded.  The multiple resources within the Department of Psychiatry, Duke University , State facilities, etc. provide a broad array of available opportunities for further specialized training.

·         Normal Child Observation –  (both years)

Residents carry out systematic observations of infants, children, and adolescents in infant care center, day care settings, kindergartens, elementary and junior high schools.  Group supervision is included in the four hours.

·         Child Psychotherapy Program –  (both years)

A child or adolescent is worked with in weekly sessions in Cognitive Behavioral Psychotherapy.  The resident also works with the parent as part of the treatment.  The case is presented to a supervisor in once/weekly case supervision

A long-term psychodynamic psychotherapy case starting in the first year is supervised weekly.

·         Individual Supervision – 2 hours/week
Supervision is provided at each clinical site by the faculty member responsible for the care
Psychotherapy supervision is part of this time

The following are examples of elective programs:

Research

            Within the Division, there is the opportunity for hands-on research with staff members in the current areas of their research:
·         Neurobiology and genetics of affective disorders.
·         Childhood epidemiology.
·         Attention deficit disorder.
·         Anxiety and Affective Disorders in children and adolescents

Clinical 

·          Substance abusing youth, attention deficit disorders, anxiety syndromes, depression, etc.
·         Eating Disorders  
·         Sexual abuse treatment – participation in evaluations and legal activities involving sexually abused youth.  
·         Anxiety and Affective Disorders in children and adolescents

Academic  

·         Organization of and participation in teaching activities with medical students and general psychiatry residents.
·         Inauguration of pilot clinical research studies which can evolve into academic clinical research activities.  

It should be emphasized that these elective areas are only a few examples of the many which are possible utilizing the multiple resources available within Duke and CPI and the surrounding university and state facilities.  A post-residency training year may e available for selected individuals in one of these specialty areas.

*Entry into the elective tracts is dependent upon the child resident demonstrating sufficient mastery of the core curriculum areas in the first residency year.  

A satisfactory clinical, clinical research or basic research paper is required for graduation.  Residents will present their papers at a child Psychiatry Grand Rounds at the conclusion of their two year residency.  Topic approval to be requested by April 1 of last year.

*Outpatient child & adolescent psychiatry clinical services at Duke:  
     Community Guidance Clinic  
               Psychopharmacology Clinic  
               Adolescent Substance Abuse Intensive Outpatient Program  
     The Duke Child & Family Study Center  
               Psychopharmacology Clinic  
               Psychosocial Treatment Clinic  
               Duke Family Studies Program- First Year  
               ADHD Program  
               Program in Child Affective and Anxiety Disorders  
               Pediatric Psychological Testing Lab  
     Center for Child and Family Health  
               Child Abuse and Neglect Assessment and Treatment  Services  
               Forensic evaluation services  
     Pediatric Neurology Clinic  
               Pervasive Developmental Delay and Autism Clinic  
               Epilepsy Clinic  
     Child Developmental Unit  
               Fragile X specialty program  
     Pediatric Mental Health Team at Pediatric Primary Care  
     Duke Eating Disorders Program- elective second year  
Outpatient Affiliated Community Practice
     Crabtree Clinic – Raleigh  
               Psychopharmacological service  

Division of Child and Adolescent Psychiatry
Summary or Research Activities
2003-2004

Adrian Angold, M.D.

Research Interests and Research Career Direction

Dr. Angold is Director of the Center for Developmental Epidemiology.  This multi-university (Duke, Emory, VCU), multi-disciplinary research consortium provides training and seed funding for those interested in the development of psychiatric disorders.  They focus particularly upon the interfaces between genetic, biological, and behavioral manifestations of disorder.

Current Projects

·         Comorbidity among psychiatric disorders
·         Depression and changes in risk for depression across adolescence
·         Psychopathology in preschoolers
·         Structured psychiatric interview development

Lisa Amaya-Jackson, M.D.

Research Interests and Research Career Direction  

Dr. Amaya-Jackson’s research interests focus on children’s exposure to traumatic life events.  Areas of study include epidemiology, treatment, and service use of traumatized children and families, with particular emphasis on Post-traumatic Stress Disorder and related comorbidity.

Current Projects

·         Longitudinal studies in child abuse and neglect (Longscan).  Dr. Amaya-Jackson is a co-investigator of the UNC Coordinating Center (Desmond Runyan, PI) of this multi-site longitudinal set of studies which follow children identified at risk for maltreatment for the course of 20 years.  (NCCAN)
·         National Institute on Child Health & Human Development funded network on child and family well-being.  Dr. Amaya-Jackson is a co-investigator in a network of researchers that use their current and collaborative data to inform policy in this area.  (NICHD).
·         Multimodal Trauma Treatment in Hamlet. CBT treatment study with Dr. John March (PI) in a school and clinic sample.  (NIMH)
·         Effects of Parental PTSD on Child & Family Functioning.  Descriptive study interviewing children and their parents who have PTSD.  (NIMH supplement to adult drug study of Dr. Jonathan Davidson).  

Paul M. Brinich, Ph.D.

Research Interests and Research Career Direction  

Dr. Brinich has been investigating the psychological vicissitudes of childhood adoption for more that 25 years in both clinical studies and descriptive research.  He also has a special interest in how children and adolescents adapt to the loss (via divorce, illness, or death) of important people in their lives.

Dr. Brinich also has been involved in the development of the Lucy Daniels Preschool, a privately-funded and psychoanalytically-guided educational program for children with a variety of developmental disturbances.  This program offers an unusual opportunity for detailed in-depth observation of developmental problems in children aged 3-6 years.  Dr. Rosenblitt, M.D. (a member of the DUMC faculty) is the medical director of the Preschool.

Barbara J. Burns, Ph.D.

Research Interests and Research Career Direction  

Dr. Burns continues her long and active investigative career in the general areas of child and adolescent psychiatric epidemiology, clinical services, and service systems research.

Dr. Burns is co-director of the Services Effectiveness Research Program. This multidisciplinary program is concerned with etiology, course, prognosis, treatment and outcomes of psychiatric disorders and utilizes public-health approaches to examine the prevalence of mental illness and its treatment in communities.

Current Projects

• The Treatment for Adolescents with Depression Study (TADS) (Barbara J. Burns).
  TADS is a randomized clinical trial of treatments for Major Depressive Disorder in teenagers. TADS will compare the short and longer term effectiveness of medication and psychotherapy, separately and combined, for major depression in teenagers. For teens treated in TADS, the trial is designed to provide best practice care for depression. The hope is that study results will improve the future care of adolescents with depression. This project is funded by the National Institute of Mental Health. (1998-2005).

• Therapeutic Foster Care in a System of Care - Competing Continuation (Betsy Farmer PI, Barbara J. Burns Co-PI, Maureen Murray, Shannon Dorsey, Eric Elbogen, Charlene Allred).

Elizabeth Jane Costello, Ph.D.

Research Interests and Research Career Direction

Dr. Costello has established a track record in psychiatric epidemiology across the life span (especially childhood, adolescence, and mid-life).  She is also interested in mental health service systems research.

 In her work as an epidemiologist she is using the data sets accessed through the Center for Developmental Epidemiology to develop a model of child psychopathology that will help integrate findings about the causes of mental illness ("etiologic epidemiology") with a better understanding of risk factors and the options for prevention ("public health epidemiology"). An important aim will be to use findings from this work as the basis for developing a set of propositions about how public health can use a primary care/primary prevention model to improve the emotional and behavioral development of children.

Dr. Costello has been awarded a William T. Grant Foundation Faculty Scholars Award.

John F. Curry, Ph.D.  

Research Interests and Research Career Direction

Dr. Curry, in collaboration with Drs. John Lochman and Edward Craighead, has studied social cognitive processes associated with externalizing (conduct disordered) and internalizing (depression) disorders in children and adolescents. His current research focuses on psychosocial interventions for adolescent depression or substance abuse.  Most of his studies involve individual, group, or family models of cognitive behavioral intervention for these disorders.  He is interested in methods of generalizing the positive results of controlled clinical psychotherapy and medication trials to broader community settings.  Other interests include functional outcomes of intervention, and the integration of empirical and narrative methods of personality assessment.

Helen Egger,M.D.

Research Interests and Research Career Direction

Dr. Egger’s  research with the Center for Developmental Epidemiology has included secondary analysis of GSMS and CCCs, the longitudinal, population-based data sets gathered on children and adolescents in rural and urban North Carolina . Using the data from these studies, I have focused on somatic complaints and psychopathology, the presentation of and course of anxiety disorders, and school refusal. More recently, I have been working on the development of a new psychiatric interview for parents of preschool children, the Preschool Age Psychiatric Assessment (PAPA).

Jeffrey Epstein, Ph.D.
Director of the Duke ADHD Program.

Research Projects at the ADHD Program

• Promoting Evidence-Based ADHD Treatment in the Community
• Multimodal Treatment Study of ADHD Children (MTA)
• Methylphenidate Efficacy and Safety in ADHD Preschoolers
• Functional Neuroanatomical deficits in ADHD Families
• Adult ADHD Study

John S. March, M.D., MPH

Research Interests and Research Career Direction

• Anxiety, obsessive-compulsive and tic disorders
• Developmental psychopharmacology  
• Clinical trials methods  
• Psychometrics/instrument development  
• CNS mechanisms of treatment response

Current Projects

PI of several NIMH funded treatment outcome studies: the Pediatric OCD Treatment Study (POTS), Research Units on Pediatric Psychopharmacology/Psychosocial Interventions, the Child Anxiety Management Study (CAMS) and of the Coordinating Center for the Treatment of Adolescent Depression Study (TADS).

Karen J. O’Donnell, M.Ed., Ph.D.

Research Interests and Research Career Direction

Dr. O’Donnell has a clinical practice and research projects in early childhood development, especially in the context of high risk biological events and processes.  She sees children and their families with concerns about in-utero drug exposure to material HIV/AIDS, pre-term delivery, and (in china) iodine deficiency.  Her research emphasizes the interactions and transactions between biological factors and the early caregiving environment in subsequent developmental outcomes as well as the early interventions that can affect those outcomes.

Dr. O’Donnell was honored for her infant psychology contributions to the field of psychology at the 50^th anniversary celebration o the North Carolina Psychological Association in 1998.

Current Projects

Teaching Relevant to Infant Psychiatry at DUMC

Individual focus on training in early infancy can be negotiated as clinical time with Dr. O’Donnell in one or more of the clinics or programs noted above.

Karen C. Wells, Ph.D.

Research Interests and Research Career Direction

Dr. Wells’ career research emphases are family processes and family therapy in childhood disorders, particularly aggressive disorders, depression, and substance abuse.

Current Projects 

• Multimodality Treatment of ADHD.  This study examines the differential efficacy of pharmacotherapy, psychosocial therapy, and their combination for treatment of childhood ADHD.   This is a multi-site collaborative study.  Dr. Wells is Primary Investigator at the Duke site.  
• Prevention of Childhood Substance Abuse.  These two projects address various questions related to child and family cognitive-behavioral intervention in the prevention of child and adolescent substance abuse.  
• Pharmacotherapy and Cognitive Behavior Therapy in the Treatment of Adolescent Depression.  This project examines pharmacotherapy alone, CBT alone, and their combination in the treatment of adolescent depression.

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