RATIONALE FOR TRAINING

Because of rapid advances in medical treatments and technologies, we are seeing rising numbers of children with developmental/behavioral difficulties as part of primary pediatric care, either as isolated conditions or in conjunction with other chronic conditions. Most children will be recognized and cared for by primary pediatricians. Recognition of developmental and behavioral issues by primary care physicians has been poor, and knowledge about referral for educational or other specialized services as well as treatment options has also been limited. Therefore, this training curriculum has been established to facilitate preparation of future practitioners for care of children in a variety of settings that incorporates a sensitivity to and knowledge of developmental and behavioral issues.

GOAL OF TRAINING

To train pediatric house officers to recognize developmental disabilities and behavioral abnormalities of children and adolescents in a timely fashion, to manage a wide range of common problems in these areas, to know which cases need referral and how to facilitate referral, and to understand the importance of community-based support and services for families.

OVERALL OBJECTIVES

Upon completion of the four-week block rotation the trainee will:

1. Demonstrate knowledge regarding the full range of developmental and behavioral issues.

2. Demonstrate an appreciation of the relevance of psychological and social aspects of well child care, acute illness, and chronic illness.

3. Demonstrate skills, which facilitate excellence in incorporating a behavioral-developmental approach to children and families.

4. Apply the acquired knowledge, attitudes, and skills in clinical pediatric settings.

METHODOLOGY OF TRAINING

A. SITES

1. Child Development Unit

• Infant evaluations
• Early Childhood Team Evaluations
• Down Syndrome Clinic
• Individual Psychological Evaluations

2. Inpatient Services

• Consultation on the floors
• Consultation to the CHP NICU

3. Additional Sites (Directions to site are included in resident binders)

CHP Programs:

1) Child Life Program - Contact person: Denise Esposto, (412) 692-5022, pager # 6231
2) Magee Hospital Infant Follow-up Clinic - Contact person: Cheryl Milford,
(412) 641-4251
3) Speech/Language Services at CHP North Satellite - Contact person:
Dave Hammer, (412) 692-3610
4) OT/PT - Contact person: Sue Oresic, (412) 692-5480
5) Spasticity Clinic – Contact person: Belinda, (412) 692-7181
6) Audiology & Communication Disorders – Contacts: Gretchen Probst, (412) 692- 7719 and Maxine Oringer, (412) 692-8469

Community Based Programs:

1) Transitional Infant Care - Contact person: Janet Laughlin, (412) 441-0700,
ext. 238
2) Center for Creative Play - Contact person: Laura Barry, (412) 371-1668,
ext. 1012
3) LEAP preschool - Contact person: Nancy Rapp, (412) 781-1708
4) Autism summer camp programs (Watson Institute) –
Contact person: Christine Gorby 412-749-2894
5) Western PA School for Blind Children - Contact person: Maryanne Loebig, (412) 621-0100, ext 242 or (412) 621-6009
6) Childs Way - Contact persons: Mary Carol Strang (412) 441-4884
7) Pediatric Alliance International Adoption Clinic- Dr. Sarah Springer, (412) 521-6511
8. The Discovery Program – Lindsay Gruber x4751
9. Early Intervention Evaluations – Sheila Cannon x7963

B. PERSONNEL

CDU is a multidisciplinary unit, employing a variety of child developmental specialists. The resident will work first hand with Developmental/Behavioral pediatricians, developmental psychologists, and other professional providers. Core Pediatric Faculty, Psychologists, and other professionals include:

Developmental/Behavioral Pediatricians and Nurse Practitioners:

William Cohen, MD
Sara C. Hamel, MD – Training Coordinator, pager 2233
Kristin Hannibal, MD
Dena Hofkosh, MD
Becky Kronk, CRNP
Susan VanCleve, CRNP

Developmental/Behavioral Pediatrician Fellows:

Diego Chaves-Gnecco, MD

Psychologists and Other Professionals:

Robert Noll, PhD- Director, CDU
Cynthia Johnson, Ph.D
Hilary Feldman, Ph.D
Stacey Munsie, LSW
Carla Weidman, Ph.D
Cynthia Milberger, MA
Patti Metosky, Ph.D
Sheila Cannon, MEd– Down Syndrome Center Coordinator
Gale Jones, RN
Helen McElheny and Sharon DiBridge, BS - Intake Coordinators
Paula Ciliberti, MA – Resource Coordinator
Amanda Pelphrey, Ph D
Diana Shellman, Ph D (8-06)
Carla Mazefsky, Ph D (8-06)

Office and Administrative Staff:

Bonny Bair – Administrative Assistant II
Mary Ann Brethold – Case Management Specialist
Susan Cohen – Secretary 1
Iris Harlan, Manager
Shirley Miller – Scheduling Secretary

C. DIRECT CLINICAL EXPERIENCE

Clinical experiences occur throughout the week, in accordance with the overall Child Development Unit schedule (See sample Appendix). Residents will participate in a variety of evaluations, sometimes as observers and sometimes performing direct patient care, under the supervision of one of the pediatric attendings. Any report writing or dictations must also be supervised or reviewed by a pediatric attending physician. Trainees will also team up with and learn from many other professionals, including psychologists, social workers, child development specialists, speech language pathologists, and occupational or physical therapists. Additionally trainees will learn from parents, and from experiences at community-based sites.

We have arranged several educational experiences outside the CDU, most of which will not include direct patient care. Trainees will work with a key mentor at each outside site. Residents continue to attend their continuity sessions during the rotation.

D. DIDACTIC EXPERIENCES

1. Articles and References addressing CORE TOPICS (On Line at Navigator Site)

• Normal Development
• Cerebral Palsy
• Neonatal Assessment/Follow-up of the High Risk Infant
• Mental Retardation/ Fragile X Syndrome
• Medical Care of Individuals with Down Syndrome
• Delivering Difficult Diagnostic Information
• Autism/ Pervasive Developmental Disorder/ Asperger’s Syndrome
• Attention Deficit Hyperactivity Disorder
• Tourette Syndrome/ Mood Disorders/ Psychopharmacology

2. Videotapes

3. Case Study/PBL Case Material

E. CORE TOPICS AND LEARNING OBJECTIVES FOR DEVELOPMENTAL/
BEHAVIORAL PEDIATRICS BLOCK ROTATION

1. Communication Skills

Learning Objectives - by the completion of training, residents will:

a. Demonstrate the ability to obtain information from children, adolescents, and families in a manner that is:

• Culturally sensitive
• Developmentally appropriate
• Family focused

b. Demonstrates skill in using appropriate interview techniques to gather information, such as:

• Use of open-ended and direct questions
• Monitoring of non-verbal communication, both of the patient and family members and of themselves
• Observing child behaviors
• Providing and receiving feedback from patient and family

c. Demonstrate skills in communicating with children, adolescents, and families in problem situations, such as working with challenging parents, giving bad news, and discussing sensitive issues.

d. Demonstrate the ability to share information clearly and concisely with professional colleagues in many venues, including during clinical situations, on rounds in formal presentations, on the telephone, and in writing. In all these forms, demonstrate sensitivity to patients and families, including respect for confidentiality.

2. Assessment Skills

Developmental-Behavioral Surveillance and Screening from Infancy
through Adolescence

Learning Objectives - by the completion of training, residents will:

a. Demonstrate an understanding of the process of developmental surveillance, which emphasizes monitoring development over time and in the context of the child’s overall well-being using historical information, parental concerns, clinical observation, hands-on examination, and family- environmental information.

b. Know the purposes for behavioral, developmental, and psychosocial screening of children in primary care practice.

c. Be able to take a thorough history through parent interview and review of
medical records to make a risk determination regarding developmental and behavioral concerns.

d. Be able to appraise developmental and behavioral status of a child at any age by observation, physical examination, and neurodevelopmental assessment.

e. Demonstrate a working knowledge of the range of instruments and techniques including interviews, standard physician check-sheets, parent- completed forms, naturalistic observation, and direct testing appropriate for screening children and families in heath care settings.

f. Be able to use preselected tools for applying biopsychosocial model to the evaluation of developmental and behavioral concerns. A resident should:

g. Be able to correctly administer and interpret at least one formal developmental screening method. This includes using screening results to give feedback to parents and to guide referral decisions.

h. Be able to use global behavioral rating scale (including both parent and teacher scales) and interview data to identify behavioral problems in need of mental health intervention and/or referral.

Neonatal Assessment/Follow-up of the High Risk Infant (CDU)

Learning Objectives - by the completion of training, residents will:

a. Enhance their understanding of the spectrum of developmental outcome of a variety of complications of the perinatal period.

b. Be familiar with the course of normal preterm development in contrast to expectations for development of the fullterm, healthy infant. This will include knowledge of appropriate expectations for "catch-up" skills.

c. Recognize abnormal patterns of neuromotor development of the high risk I infant, including the ability to distinguish signs of "transient dystonia" and signs suggestive of more permanent disability (CP).

d. Be more familiar with the presentation and methods for assessment of subtle
language, fine motor and cognitive deficits in the course of development of the high risk infant.

e. Be able to discuss issues related to the well child care of the preterm high risk infant.

f. Become more sensitive to the family's experience of a high risk birth, including: demonstrated respect for parents' concerns, awareness of differences in preterm infants' weight gain, feeding, appearance, sleep/wake cycles, and behavior, and appreciation of the parental perception of child vulnerability and how this impacts on family functioning.

3. Diagnostic Classification Schemas

Learning Objectives - by the completion of training, residents will:

a. Be familiar with DSM-PC codes (child manifestation and environmental situations codes) to children with developmental and behavioral concerns. The resident will be able to differentiate childhood manifestations as developmental variations, problems, or disorder-level conditions.

b. Be familiar with DSM-IV and its multiaxial system as it applies to children with diagnosed mental disorders.

4. Evaluations by Other Disciplines

Learning Objectives - by the completion of training, residents will:

a. Be able to determine the need for assessment by other professionals. Specific discipline competencies include:

• Psychiatry, Adults and Child
• Occupational and Physical Therapy
• Neurology
• Educational Specialties
• Psychology
• Social Work
• Speech Pathology
• Audiology
• Child Life
• Genetics

b. Formulate effective referral questions to appropriate professionals.

c. Be able to interpret the results of evaluations by other professionals.

d. Be able to use information from other professionals to guide decisions for additional evaluations and interventions.

e. Understand the use of evaluations by other disciplines in the eligibility determination for early intervention and special education services (See also V.G.2., “Knowledge of Other Disciplinary Treatments.”)

f. Be familiar with federal laws such as the Individuals with Disabilities Act, Section 504 of the Rehabilitation of the Handicapped and the Americans with Disabilities Act and their implications for patients with educational concerns.

5. Developmental and Behavioral Symptoms and Disorders

This section refers to conditions at the Problem and Disorder levels as categorized in the DSM-PC. Readers may find some unavoidable overlap with topic objectives in the preceding section.

Developmental Disabilities

Learning Objectives - by the completion of training, residents will:

a. Be able to generate a differential diagnosis for the child with persistent
global developmental delays.

b. Be able to generate a differential diagnosis for the child with persistent
motor delays, such as cerebral palsy, developmental coordination disorder, and other neurodevelopmental and general medical conditions.

c. Be able to generate a differential diagnosis for the child with abnormalities
in speech and language development, such as language disorders, stuttering,
and other medical conditions.

d. Be able to generate a differential diagnosis of the child with persistent
learning difficulties.

e. Be able to coordinate an evaluation of a child with persistent developmental systems, after having generated a differential diagnosis.

f. Know the role of early intervention programs in the evaluation and treatment
of children with developmental delays or those who are at risk for such
delays.

g. Know the effects that developmental disabilities can have on the child and
family functioning and how to assist with them.

h. Know common medical complications associated with cerebral palsy,
moderate to severe mental retardation, Down syndrome, and
myelomeningocele.

i. Know effective therapies available for patients with cerebral palsy, mental retardation, genetic disorders, and myelomeningocele.

j. Be able to coordinate comprehensive care for patients with cerebral palsy,
various degrees of mental retardation, genetic disorders, and myelomeningocele.

Learning Objectives Specific to Cerebral Palsy (CDU)

Learning Objectives - by the completion of training, residents will:

a. Recognize the significance of patterns of neuromotor abnormality and the
evolution of neuromotor signs in the diagnosis of the different forms of
cerebral palsy.

b. Demonstrate, by the use of appropriate medical testing such as
neuroimaging, an understanding of the differential diagnosis and etiologies
of cerebral palsy.

c. Discuss the problems frequently associated with cerebral palsy (sensory
impairment, mental retardation, language problems) and will refer children
appropriately for evaluation of these problems.

d. Discuss controversies concerning the value of early intervention for children
with CP, and will be aware of existing services in the community and will
make appropriate referrals for these services.

e. Enhance their appreciation of when and how the diagnosis of CP should be discussed with families.

Learning Objectives Specific to Mental Retardation/Fragile X

Learning Objectives - by the completion of training, residents will:

a. Know criteria for diagnosis and how children may vary, also how different
systems vary in criteria (e.g., state of PA)

b. Know common and uncommon presentations and ddx.

c. Know the approach to dx, workup of suspected case.

d. Know the fundamentals of initial management.

e. Know the natural history and issues for the gen. pediatrician in the care of
these children.

Learning Objectives Specific to Medical Care of Individuals with Down Syndrome

Learning Objectives - by the completion of training, residents will:

a. Discuss the current guidelines for preventive medical care of individuals
with Down Syndrome.

b. Understand the medical approach to the newborn with suspected DS.

c. Learn the four basics referrals for infants with DS.

d. Learn about the current range of functioning for individuals with DS of all ages.

e. Role play and discuss making the presumptive diagnosis of DS following the unexpected birth of a baby with phenotypic characteristics of the disorder.

Learning Objectives for Delivering Difficult Diagnostic Information

Learning Objectives - by the completion of training, residents will:

a. Role play and discuss making the presumptive diagnosis of DS following the unexpected birth of a baby with phenotypic characteristics of the disorder.

b. Interview parents regarding the informing process and ask how they might want this to have been different (blind institute video).

c. The resident will become familiar with recent studies on good ways to give bad news.

Impulsive/Hyperactive or Inattentive Behavior

Learning Objectives - by the completion of training, residents will:

a. Be able to generate a comprehensive differential diagnosis to assess the concerns of parents regarding either child’s disruptive, overactive, impulsive, and/or inattentive behaviors.

b. Be able to describe the natural history of ADHD and how its presentation varies with developmental progression.

c. Be able to list and recognize the common mental health and learning comorbid conditions that can present with symptoms suggesting ADHD.

d. Be able to use history, physical examination, child observations, parent and teacher questionnaires, and child and family interviews in evaluating symptoms of impulsivity, hyperactivity, and inattention.

e. Be able to appropriately use additional disciplines in the evaluation and treatment of symptoms of impulsivity, hyperactivity, and inattention.

f. Be able to assist families in initiating behavioral, cognitive, academic, and pharmacological interventions in children with ADHD behaviors (see
Section V.B.1.d., “Basic Psychopharmacotherapy”).

Atypical Behaviors/Disordered Relationship Skills

Learning Objectives - by the completion of training, residents will:

a. Demonstrate a working knowledge of, and be able to manage effectively, repetitive behavior problems and disorders, such as head-banging and other self-injurious behaviors, trichotillomania, transient tic disorders, and Tourette syndrome.

b. Describe the clinical manifestations of problems involving social interaction behaviors including pervasive developmental disorders (PDD) and autism, including Asperger Syndrome.

c. Distinguish pervasive developmental disorders from other childhood disorders.

d. Be able to develop a complete differential diagnosis for PDD spectrum disorders.

e. Be able to determine whether a child with social interaction difficulties needs referral for further evaluation for PDD spectrum disorders.

f. Be familiar with appropriate long-term management techniques and necessary components of an effective educational and/or habilitation program for children and youth with PDDS.
g. Recognize bizarre behaviors in children (e.g. delirium, psychotic behaviors, agitation, disorientation, memory impairments); determine whether they are
caused by medical condition, substance abuse, or mental disorder; and intervene accordingly.

Tourette Syndrome, Mood Disorders, Psychopharmacology

Learning Objectives - by the completion of training, residents will:

a. Learn the more common comorbid conditions associated with ADHD and /or learning problems in the school age child, and how to differentiate them.

b. Learn how the presence of comorbid conditions complicates the treatment of ADHD and learning problems.

c. Learn how to diagnose more common psychiatric conditions in school age children, such as anxiety and depression, and the approach to treatment.

Basic Psychopharmacotherapy

Learning Objectives - by the completion of training, residents will:

a. List indications for the use of medications in the management of common mental diagnoses in pediatrics, such s ADHD and mild depression.

b. Identify the stimulant class medications most commonly used in the treatment of ADHD, their benefits, side effects and risks.

c. Identify the second-line medications most commonly used to treat ADHD either alone or in conjunction with stimulant medication, along with their benefits and side effects.

d. Identify antidepressant medications used in pediatric populations as adjunct t treatment for ADHD and for mild depression in adolescents.

e. Describe management strategies for patient who have poor response to medication or for whom medication no longer seems as effective as in the past.

f. Recognize other medications that may be prescribed as treatment for children with psychiatric conditions.

6. Knowledge of Other Disciplinary Treatments

Learning Objectives - by the completion of training, residents will:

a. Be knowledgeable about early intervention (EI), including:

• EI legislation: Know criteria for eligibility within the resident’s state for Part H services, including establishing risk conditions
• Local resources and service providers.
• Procedures for identifying children for potential eligibility for services.
• Specific steps within the state for referring a child into the EI system.
• Physician’s role in providing medical home and assistance in on-going service coordination for children receiving EI services.

b. Be knowledgeable about educational interventions, including:

• Legislation related to mandates for educational services for handicapping conditions.
• Handicapping conditions recognized by the public educational system.
• Multifactored evaluation procedures used for determining eligibility for special education services.
• Physician’s role in on-going service coordination for children receiving special education services.

c. Recognize when a child or family might benefit from a referral to receive therapeutic interventions such as:

• Speech and language therapies
• Occupational and physical therapies
• Clinical hypnosis
• Biofeedback
• Emerging gene therapies

d. View themselves as a member of the child’s treatment team and understand the importance of on-going communication and cooperation with other professionals involved in a patient’s care (see also Section V.C.3., “Evaluations by Other Disciplines).

7. Knowledge of Hospital and Community Resources and Support Services

Learning Objectives - by the completion of training, residents will:

a. Have a working knowledge of roles and functions of the non-medical resources and support programs serving children and families within the hospital setting, such as social work, child life, allied health therapies, pastoral care, and NICU developmental specialists.

b. Have a working knowledge of the range of community-based resources for children and families as well as what services are provided and the characteristics of client populations serviced at different types of sites.

8. Illness Related Adaptation of Families and Children

Learning Objectives-by completion of training, residents will:

a. Counsel families regarding the developmental progression of how children typically think about illness and health and how to improve their understanding to better cope with illness.

b. Counsel families regarding the impact of acute illnesses, physical
disabilities, sensory impairments, and hospitalizations on child behavior and development.

c. Counsel families regarding the impact of chronic illness and terminal conditions on development and behavior from toddler hood through adolescence.

d. Understand the impact of a chronically ill child on family relationships
and the available mechanisms of support.

e. Use an understanding of the child's developmental level to provide anticipatory guidance, and discuss the management of acute and chronic illness with patients and families.