Child/Adolescent Psychiatry Inpatient Rotations
Medical Student
Welcome to the Child and Adolescent Psychiatry Inpatient rotation! Three weeks is a
short time, and we want you to learn as much as you can while you're here with us. One
of the most unique aspects of this rotation is the many opportunities to learn. You'll see
that each member of the treatment team has an area of expertise - feel free to ask
anyone any questions that you have. You'll be able to appreciate how normal
development at any age may be affected by emotional/behavioral issues.
Objectives
• To become familiar with the psychiatric and social difficulties experienced by
children, particularly those disorders first diagnosed in children and adolescents by
DSM-V, and the differences in the presentations of these illnesses
• To understand and participate in the medical workup for acutely ill child/adol
psychiatry inpatients
• To learn how to interact with psychiatrically ill children and to perform the mental
status exam
• To appreciate the multidisciplinary approach to diagnosing psychiatric disorders in
children (MD, psychology, nursing, social work, education, occupational therapy,
recreational therapy, and speech/language assessments)
• To appreciate the team approach to the acute inpatient management of child
psychiatric disorders, including pharmacotherapy, psychotherapies, occupational
therapy, recreational therapy, social/environmental and school interventions
• To appreciate the importance of the family/support system in the discharge
planning for children who have been hospitalized
Competency Building
• Skills in interviewing children and adolescents about sensitive topics such as
sexuality, substance use, physical/sexual abuse
• Mental status exam skills in interviewing and in presentation
• Obtaining developmental histories from parents
• Education of adolescents and parents about topics such as substance abuse
sexuality, STD's as well as psychoeducation re: diagnoses and medications
• Communication skills in dealing with parent-adolescent conflicts
• further development of organizational skills in patient care, including interview
techniques, presentations and progress notes
Child and Adolescent Inpatient Psychiatry, Medical Student Orientation
Last updated July 2014
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Expectations
Arrive by 8:00 am (or the prearranged time with your attending)
• Check in with your resident{s)
• Review nursing notes, get details from nursing staff.
• See vital signs, sleep chart, use of prn's over last 24 hrs.
• Check labs
• Check in with patients re: problems, side effects from meds
Participate in Community Meeting (on Adolescent)
• Facilitate input from your patients, focusing on their progress on daily goals on the
unit.
• Ask about contact with family and progress toward discharge goals.
• Facilitate feedback from staff and peers.
• While some inquiry into symptoms may be appropriate, avoid specifics re:
diagnostic test results and medications.
• Give feedback to other patients as indicated, as well as comments as to community
issues.
Attend Treatment Team
• Briefly present each assigned patient
• Facilitate input from treatment team members
• Summarize the treatment plan for the day
After Team
• Clarify questions from team with resident/attending, staff, social work.
• Work with resident{s) on writing orders on EPIC, following up on tests, lab work,
making contacts, etc.
• Participate in scheduled family meetings involving your patients.
• See your patients to work on rapport building, supportive work, goal work, safety
plan, and home rules contract.
• Participate in therapeutic groups, occupational therapy (OT), recreational therapy
(RT) and school
Other Expectations
• Document progress notes in EPIC; have resident review for feedback.
• Use time in the afternoons not spent with patients, groups, and families to look up
information on clinical topics of interest related to adolescent issues. You're
encouraged to present on a topic to the team.
• Complete one history and physical assessment, including differential diagnoses and
preliminary treatment plan; present it to your attending.
Child and Adolescent Inpatient Psychiatry, Medical Student Orientation
Last updated July 2014
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Working with your patient
One of the biggest challenges in working with children and adolescents is how easily
we're reminded of our own childhood. This can enable us to develop rapport with our
patients. However, if we're not careful, boundaries can blur and this may adversely
affect the therapeutic alliance. A few pointers:
• Playing a game with your patients is a great way to establish rapport. Be sure to
follow this up with some discussion of your patients' issues and goal work.
• While empathy is important, avoid sharing your own personal experiences with
your patients.
• Meet with your patients where others can see you.
• Physical exams should be done in the treatment room with a chaperone of the
same gender of the patient.
• If you feel uncomfortable or confused about an interaction with a patient, don't
hesitate to seek guidance from your resident or attending.
A Note on Confidentiality
Most of what an adolescent will tell us will be confidential, i.e. we do not share with
parents unless the adolescent gives us permission. The only exceptions are issues
that involve harm to self and/or others. Please remember the following:
• Federal law prohibits us from giving any information about an adolescent's
substance use to others without the adolescent's permission; this includes
results of drug screens.
• The adolescent should be told that you may need to share otherwise
confidential information with your resident, attending and/or treatment team,
who of course will respect the patient's confidentiality.
• Sexual information (except that involving harm to self/others) are also
confidential, so the adolescent can consent to an HIV test and contraception
• Therapeutic goal should be to help the child/adolescent become able to discuss
their issues with their parents, either independently or with our support
Child and Adolescent Inpatient Psychiatry, Medical Student Orientation
Last updated July 2014
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Working with families
You'll discover that more often than not there is a high degree of discord between the
patients and their family members. Therefore, we do a lot of work with patients and
families, which typically follows this pattern:
• Meeting with the parents and child/adolescent separately to get an idea of the
problems(s) from every perspective
• Educating the family re: the patient's issues, treatment and the family's role in
recovery.
• Helping the patient take responsibility ( a s d e v e l o p m e n t a l l y a p p r o p r i a t e )
for his/her role in the family conflict
• Assisting the patient in assertive communication of the progress made and what
he/she will need from the family on discharge
• Counseling the family on assertive communication techniques
• Allowing the patient and family to work together to achieve these goals using
Home Rules Contract
Helpful ideas in communicating with parents:
• Begin by joining your resident, attending and social workers in their contacts with
families. Offer your observations based on your interactions with the patient.
• It may be useful to make the goal of your initial parent contacts to relay factual
information – e.g., lab results, consult recommendations.
• Use your alliance with the patient as a means of gaining the confidence of the
family; you may be "the expert" as to how the patient is really feeling, what they're
really thinking.
• Let your resident, attending and/or social worker know if you have any concerns
re: family contacts
A Note on Informed Consent
Given that parents/guardians must consent for all psychotropic medications we
prescribe for minors, and that the evidence base for many of the medications is
limited and therefore prescribing is sometimes "off- label," UNC Hospitals takes
informed consent very seriously.
Document in your progress note that you have discussed”
• Indication(s) for medication/potential benefits
• Potential risks/adverse events
• Treatment alternatives, risks/benefits
• Risks/benefits of not
• "Off-label" status if applicable
Parents can sign the medication consent form, or you and a witness can sign the
form if consent is by phone.
To this end, we recommend the AACAP-endorsed website
www.parentsmedguide.org to parents of children or adolescents being prescribed
antidepressants.
Child and Adolescent Inpatient Psychiatry, Medical Student Orientation
Last updated July 2014
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Try to Get Some Experience With
• Managing challenging parent-child conflicts
• Teaching patients and families about diagnoses and treatment
recommendations, relapse prevention strategies
• Group process in the therapeutic community, community meeting
• Cognitive Behavioral Therapy (CBT) related to depression, anxiety, anger
management, relaxation techniques
• Daily goal selection
• Home Rules Contract – work with patient and parents
• Safety Plans and recommendations to parents
• Packets: Self harm, Anger management, depression, Parent Teen Communication,
Assertive Communication, If I Could Run My Family Packet.
• Rating Scales: Adolescent Depressive Inventory (CDI), Trauma Symptom Checklist
for Children (TSC-C), PTSD Checklist, Connors rating scales, Mania Rating Scales
(MRS), Adolescent Yale Brown Obsessive Compulsive Scale (C-YBOCS)
•Psychology Consults, Minnesota Multiphasic Personality Inventory for Adolescents
(MMPI-A)
•Community liaison for additional services, levels of care· (from Social Work)
Child and Adolescent Inpatient Psychiatry, Medical Student Orientation
Last updated July 2014
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Child and Adolescent Inpatient Rotation, Medical Student Orientation
Last updated July 2014