Childhood chronic illness is a significant health concern. As medical treatments improve, more children are living longer with chronic illnesses. It has been estimated that 15 to 18% of children in the US are living with a chronic illness. Of these, about half experience a restriction in their ability to participate in typical activities. Medically fragile children and their families experience a wide range of unique stressors, yet many do not have access to quality mental health services. Uniquely tailored psychological services, such as specialized assessments, psychosocial support, more intensive psychotherapy, and consultation with medical teams can have a very positive effect on quality of life for children and their families. In recognition of these positive effects, children’s hospitals and clinics are increasingly working closely with psychologists and other mental health professionals to provide comprehensive services to their patients. The psychology post-doctoral fellowships at CHOC Children’s seek to train psychologists to work effectively with medically fragile children and their families within the context of hospital based inpatient, clinic, and outpatient services. This is a particularly exciting time to be a part of pediatric psychology as the medical field increasingly understands the critical role of psychological factors in overall health and thus is increasingly involving psychology services into standard health care services. Fellows will apply their knowledge of child development and their skills as a child therapist to children affected by medical illness through a wide variety of experiences, such as inpatient consultation-liaison services to a variety of medical specialty units, more intensive experiences with specific medical specialty teams, and outpatient therapy. In addition to the intensive experiences with children with medical diagnoses, fellows will work with more traditional child outpatient therapy and/or psychological and neuropsychological assessment cases.
In order for the fellow to take a leadership role in program, our fellowships are designed to focus in a primary area. This focus allows fellows opportunities to work with teams over a year long period and to develop mastery of these skills.
One of the clinical fellowships will primarily work with the oncology program, one-two fellows will primarily work with the CHOC Consultation and Liaison Team, and two will work with our Co-Occurring Clinic offering mental health services to children with co-occurring medical and mental health conditions. Depending on funding, an additional fellowship may be available working with the Neurology Service, with a focus on neuropsychological assessment. Fellows will coordinate with the respective medical teams throughout the year, participating in clinical work, program development and clinical research activities within the teams. Fellows will see more complex cases and be responsible for further developing clinical services with the medical teams. They will participate in outpatient clinics with the multi-disciplinary medical teams, provide inpatient consultation services to patients followed by the medical team, and potentially submit a poster and/ or write a paper within their area of specialization.
I. Oncology Track (1 position):
The fellow will work with the Oncology Medical team and the interdisciplinary psychosocial team (which includes psychologists, social workers, child life specialists, teachers, and chaplain) to provide coordinated services to children diagnosed with cancer and their families. Fellows will be involved with the new diagnosis program, which includes initial coping assessments of all newly diagnosed patients and their families. After these individualized initial assessments, the fellow will provide ongoing therapeutic services as needed to each child/family (in both medical inpatient and outpatient settings). Therapeutic services include assisting children and families in the initial adjustment to a new cancer diagnosis and facilitating effective coping, helping parents and/or the medical team with behavioral management issues, psychotherapy to address pre-existing or secondary mental health issues (e.g., depression, anxiety), pain management assistance, and help in dealing with death and dying issues as well as with survivorship issues. In addition, the fellow may assist in school reintegration activities, which includes working with children who are ready to return to the school setting after completing their intensive treatment or who are struggling in school after completing their treatment. Activities might include assessments to determine their particular learning strengthens and challenges, working with schools to develop appropriate educational programs (which might include attending IEP meetings), presenting educational programs in the schools to fellow students and/or teachers, or providing psychotherapy to reduce anxiety or depression.
In addition to the experiences working with the medical teams described above, the fellow will also participate in a range of other pediatric psychology experiences described below in the section, “Activities Common to All Tracks.”
II. Consultation and Liaison Track (1-2 positions):
One to two fellow(s) will work with the Consultation and Liaison Team which provides inpatient consultation to the medical units at Children’s Hospital of Orange County. Common consults include ruling out psychosomatic causes of medical symptoms, assessing depression and anxiety and providing referrals and/or treatment, teaching children and families non-pharmacologic pain control strategies, acute stabilization of children or adolescents with eating disorders, neurologic complications, acute stress reactions, and adjusting to a new medical diagnosis. The fellow will work with interdisciplinary psychosocial teams (social workers and child life specialists) as well as with nurses, medical attendings and house staff (medical residents and fellows) as well as medical students, and case managers. Depending on the diagnosis, physical and/or occupational therapists, dieticians, pharmacists, and other specialists might also be involved. Fellows will attend medical rounds on several floors to provide information to medical professionals. The fellow will have the opportunity to run psychosocial rounds on the Medical-Surigical Floors on a weekly basis. The fellow will also have an opportunity to work closely with the Pediatric Intensive Care Unit (PICU) at CHOC. The PICU team consists of attendings, fellows, medical residents, social work, child life, psychology, nutrition, pharmacists and physical and occupational therapists.
The fellow will have the opportunity to participate in the research activities of the UCI Center on Stress and Health. The UCI Center on Stress and Health is part of the Department of Anesthesiology and Perioperative Care, at the University of California-Irvine (UCI) and Department of Pediatric Psychology at CHOC Children’s (CHOC). The Center on Stress and Health is a collaborative group from diverse areas in medicine, nursing, and psychology. Under the Direction of Dr. Zeev Kain, and Dr. Michelle Fortier, the center conducts cutting edge research on children’s health with particular interests in medical anxiety and pain. The Center on Stress and Health was first established by Dr. Kain under the name, the Center for the Advancement of Perioperative Health (CAPH) which relocated from Yale University to UCI/CHOC in July 2008. The multi-disciplinary research team has a number of ongoing federally funded projects examining perioperative pain and anxiety as well as procedural pain and anxiety. The fellow will have an opportunity to participate in projects and complete a poster and paper.
In addition to the experiences working with the medical teams described above, the fellow(s) will also participate in a range of other pediatric psychology experiences described below in the section, “Activities Common to All Tracks.”
III. Pediatric Psychology Track (2 positions):
Two fellows will work within our innovative Pediatric Psychology Co-Occurring Clinic. Both fellowship positions focus on working with children and families with a broad range of medical disorders and co-occurring psychological/psychiatric diagnoses. The structure of this clinic allows clinicians to follow families throughout the treatment and in a variety of settings. Common diagnoses include diabetes, cancer, cystic fibrosis, pain disorders, headaches, epilepsy, and GI conditions. Fellows will work with the medical teams to coordinate psychological services with medical care. The fellows in these positions will provide continuity of care to patients through outpatient and inpatient stays. In these positions, the fellows will provide initial services to families within the medical subspecialty clinics, transitioning families to psychology offices once families have identified their goals. Likewise, the fellows may start working with families while they are on an inpatient medical unit and transition them to follow-ups in medical clinics or through the outpatient clinic. The co-occurring clinic includes mental health providers from a variety of disciplines such as psychologists, psychiatrists, and licensed clinical social workers. Thre are possibilities to work with the Social Services Agency following children at risk of or who have been removed from the home for non-adherence or in providing psychological services through the child’s school. The fellows in these positions also will have the opportunity to participate in workshops and evidence based trainings provided by Orange County Behavioral Health.
In addition to the experiences working with medical teams described above, the fellows will also participate in a range of other pediatric psychology experiences described below in the section, “Activities Common to All Tracks.”
IV. Epilepsy Track (1 position, contingent on funding):
The fellow in this position will work closely with the Neurology service, with a focus on patients with epilepsy. CHOC has a Level IV Epilepsy Center and has a busy EEG monitoring program and also conducts epilepsy surgeries. The fellow in this position will work closely with our board certified neuropsychologists in performing assessments, with a focus on pre-surgery epilepsy evaluations. In addition, the fellow may have the opportunity to participate in a specialized neurology clinic with a focus on epilepsy. The fellow will provide consultation to the EMU (EEG Monitoring Unit) to assist the medical team in managing patients and addressing psychological symptoms. The medical team is intradisciplinary in nature, including epileptologists, other neurologists, hospitalists, nurses, nurse practitioners, social workers, child life specialists and pharmacists. Fellows in this position may not follow outpatient cases, but will participate in the Behavioral Emergencies On Call, Supervision Experiences and Seminars. The fellow in this position will also serve as a teaching assistant for the Neuropsychological Assessment Seminar which is a weekly, year long teaching seminar. Finally, the fellow in this position will also participate in a biweekly journal club focused on neuropsychological literature.
Activities Common to All Tracks:
The fellows in the co-occurring track will see a larger outpatient caseload (see types of cases described above in the co-occurring clinic description), while the fellows in the oncology, consultation-liaison, and neurology tracks will see a limited number of child outpatient cases. The focus will be more on children with medical diagnoses and many cases may be referred from the primary medical team placement (oncology or consultation and liaison). Referrals may include children and families coping with a medical diagnosis, noncompliance with medical treatment recommendations, and pain control. Fellows may also follow children with more traditional outpatient referrals, including depression, attention and behavior problems, anxiety, and family conflict.
Behavioral Emergencies On Call:
A distinctive feature of our program is that all trainees receive training in managing behavioral emergencies through the provision of consultation services to the CHOC Emergency Department and hospital inpatient medical units. Interns and post-doctoral fellows rotate taking after hours call throughout the year for high risk consults. Trainees are always paired with a faculty member for this coverage. High risk consults include assessment of suicide risk or acute mental status changes. Trainees will conduct a brief clinical interview, provide crisis intervention and immediate disposition plans for the suicidal patient, the potentially aggressive patient, and the psychotic patient. The Post-doctoral fellows will participate in no more than 10 weeks of call per year.
Postdoctoral fellows will be provided with an opportunity to supervise interns and/or practicum students. Training in the provision of supervision will be provided. Supervision and responsibility for the patients will ultimately be the responsibility of a licensed clinical psychologist on staff. Depending on the specialty track, fellows will either supervise therapy cases, assessments, or inpatient consult cases.
Fellows receive a combination of individual and group supervision (a minimum of four hours) per week. Supervision occurs on an individual basis, during group rounds, within clinic settings, and within the Training Program seminars. All supervision is performed by departmental staff who meet the California Board of Psychology requirements and CHOC Hospital’s Medical Staff qualifications.
Fellows are offered at least two hours of individual supervision per week for ongoing therapy cases and rotational experiences. Supervision of consults is handled with both individual supervision and via group supervision (rounds). Rounds are co-led by a board certified child and adolescent psychiatrist/ pediatrician and a licensed psychologist. The amount and frequency of this supervision will vary depending on the complexity and number of consults received. Typically, consultation supervision occurs for 1 to 2 hours weekly. Additionally, consultation services are often provided using co-therapy, especially for high risk and complex consults. Therefore, fellows are able to observe their supervisors providing psychological services. They are also able to do co-therapy and receive immediate feedback based on direct observation of clinical skills. Supervision is also provided informally during medical rounds. Fellows will be assigned one outpatient therapy and/or assessment supervisor who will work with them throughout the year on more long term outpatient therapy cases.
Training Program Seminars
Postdoctoral Fellow Seminar (weekly, year-long))
Multicultural Seminar (weekly, 5 months)
Ethics Seminar (weekly, 3 – 4 months)
Pediatric Psychology Seminar (occurs weekly, fellows serve as a teaching assistants and assist in coordinating the seminar and fellows rotate attending the seminar throughout the year, attend at least 5 weekly sessions to address any training gaps and all trainee presentations)
Neuropsychology Seminar (occurs weekly,the neurology fellow would serve as a teaching assistant, other fellows may attend any sessions to address any training gaps)
Pediatrics Grand Rounds (weekly)
Hematology Teaching Rounds (monthly)
Content of required seminars is biased in the direction of material needed for CHOC clinical activities. A didactic element is included in all seminars. Professional issues are addressed throughout the training year. Outside speakers with a particular area of expertise are invited to present several of the seminars. Trainees may also attend the CHOC Grand Rounds as time permits.
Postdoctoral Fellowship Seminar:
This seminar is held weekly throughout the year. The seminar focuses on professional development and also provides training in supervision. The seminar is informal in nature and covers topics relevant to your own training interests and needs.
This seminar is designed to focus on learning and applying an approach to your clinical work that supports increased cultural competency. The seminar is interactive in nature and consists of self-exploration activities, exploration of the surrounding community (through research and an experiential activity), presentations from professionals, as well as trainee case presentations. While we expect multicultural awareness to permeate all of your work throughout the year, this seminar is designed to help you develop your model of learning and practice.
Cases in medical settings can bring a multitude of ethical challenges, which don’t always offer clear directions for change. In this seminar faculty present cases they have worked on that have presented ethical challenges. In these interactive presentations, faculty, postdoctoral fellows, and interns discuss systems and strategies to assess ethical dilemmas and determine courses of action.
Pediatric Psychology Seminar:
This weekly seminar focuses on topics relevant to the practice of Pediatric Psychology. Presenters include physicians and other medical staff as well as psychologists experienced in particular areas. Topics include medical treatments for common medical problems, as well as psychological problems associated with those disorders. Special topics include issues such as pain control, acupuncture and traditional Chinese medicine, helping children and families cope with death and dying, and feeding issues, etc. Postdoctoral fellows serve as teaching assistants for this seminar and help to coordinate the seminar. They alternate attending the seminar throughout the year and all fellows attend all trainee presentations at the end of the year.
Neuropsychological Assessment Seminar:
This weekly seminar focuses initially on learning assessment instruments commonly used at CHOC. From there the seminar reviews the areas of function assessed in the neuropsychological evaluation, and then focuses on specific illnesses and disorders that are typically seen at CHOC, including epilepsy, traumatic brain injuries, and infant and developmental problems. The fellows may select to attend seminars with topics that address specific training needs.
Postdoctoral fellows make formal case presentations in the Pediatric Psychology Seminar (one therapy case), as well as more information presentations/consultations in Multicultural Seminar (case presentation), Postdoctoral Fellowship Seminar (supervision consultation), Ethics (case presentation), and Chispa (case consultation).