Child Psychiatry
**All Goals and Objectives for this rotation are identical across all PL years**
Primary Goals for this Rotation
/ CompetenciesGOAL I: Prevention (Dev-Beh). Understand the role of the pediatrician in the prevention of developmental and behavioral problems in children.
- Describe the common environmental, social and family influences that promote optimal development and behavior of a child.
- Describe the common environmental, social and family influences that interfere with the typical development and behavior of a child.
- Advocate for patients with special developmental, behavioral, and educational needs.
GOAL II: Normal vs. Abnormal (Dev-Beh). Develop a working knowledge of typical development and behavior for children and families and apply this knowledge in the clinical setting to differentiate normal from abnormal states.
- Counsel parents about typical parenting issues (related to child development, behavior, health and safety, family adjustment).
- Diagnose and manage specific pediatric behavioral, developmental and medical problems using knowledge and insight about family development and family systems theory.
- Use standardized, validated and accurate developmental and behavioral screening instruments, plus skills in interview, exam and medical knowledge to identify patterns of atypical development, such as:
b)Behavioral screening questionnaire (e.g., Eyberg Child Behavior Inventory, Pediatric Symptom Check List, PEDS, ASQ-SE)
c)Developmental screening tools reliant on parental report (e.g., ASQ, PEDS, CDIs)
d)Language screening
e)Home and parent risk assessment tools to screen for social concerns, e.g., alcohol abuse, domestic violence, depression (e.g., Family Psychosocial Screen, Edinburgh Depression Inventory)
/ K, PC
- Select, perform and/or interpret appropriate clinical tests to establish a medical etiology of identified developmental and/or behavioral problems, such as:
b)Neuroimaging studies and others (such as head MRI)
/ K, PC
- Demonstrate familiarity with commonly used clinical and psychoeducational testing used by specialists to evaluate and monitor children with developmental and behavioral problems.
b)Recognize common diagnostic measures of achievement, speech-language, and adaptive behavior (e.g., WRAT-R, Vineland Adaptive Behavior Scales, Preschool Language Scale-IV).
c)Understand the meaning of quotients and percentiles, the range of possible scores, common averages and standard deviations.
d)Know the scores typically observed in children with specific developmental conditions such as mental retardation, learning disabilities, giftedness, etc.
/ K, PC
GOAL III: Undifferentiated Signs and Symptoms (Dev-Beh). Evaluate and manage common developmental-behavioral signs and symptoms in children.
- Perform an appropriate problem-oriented interview and physical examination.
- Obtain additional information from other related sources (e.g., day care, school).
- Formulate a differential diagnosis, including typical variants where appropriate.
- Use structured screening instruments as appropriate.
- Formulate and carry out a plan for evaluation.
- Develop a management plan with the patient and family.
- Demonstrate effective communication to insure accurate history-taking, patient and family understanding, mutual decision-making, and adherence to therapy.
- Provide appropriate follow-up, including case management, when multiple disciplines are involved.
- Evaluate and manage the following developmental-behavioral signs and symptoms, provide appropriate counseling to parents or patients, and identify appropriate referral resources:
b)Hyperactivity
c)Delay in a single developmental domain
d)Delay in multiple developmental domains
e)Sleep disturbances
f)Elimination disturbances
g)Feeding and eating disturbances
h)Poor academic performance
i)Loss of developmental milestones
j)Regression of behavioral self-control
k)Excessive out-of-control behaviors (e.g., anger outbursts)
l)Abrupt change in eating, sleeping, and/or socialization
m)Anxiety
n)Depressed affect
o)Grief
p)Sexual orientation issues
q)Gender identity issues
r)Somatic complaints
s)Obsessive-compulsive symptoms
t)Separation anxiety
u)Tics
v)Somatic complaints
w)Aggression
x)Excessive concerns about body image
/ K, PC, IPC, SBP
GOAL IV: Common Conditions Generally Referred (Dev-Beh). Recognize, provide initial management, appropriately refer, and provide primary care case management for common developmental or behavioral conditions that often need additional diagnostic and/or management support from other specialties or disciplines.
- For the more complex developmental-behavioral problems that require referral for diagnostic or management support:
b)Discuss environmental and biologic risk factors.
c)Identify alternative or co-morbid conditions.
d)Describe natural history.
e)Organize initial assessment, consultation, and ongoing management as the primary care pediatrician.
/ K, PC, IPC
- Recognize, provide initial management, appropriately refer and provide primary care case management for the following developmental-behavioral conditions:
b)Language and learning disabilities
c)Motor disabilities (e.g., cerebral palsy, muscular dystrophy)
d)Autistic spectrum disorders
e)Attention problems, moderate to severe
f)Externalizing disorders (e.g., violence, conduct disorder, antisocial behavior, oppositional defiant disorder, school failure, excessive school absences, firesetting)
g)Internalizing disorders (e.g., adjustment disorder, anxiety disorder, conversion reactions, somatoform disorders, school phobia, depression, mood disorders, suicide contemplation or attempt, PTSD)
h)Substance abuse
i)Social and environmental morbidities (e.g., physical abuse, sexual abuse, parental health disorders such as depression and substance abuse)
j)Problems of feeding, eating, elimination, sleep
k)Atypical behaviors (e.g., post traumatic stress disorder, psychosis)
l)Problems of gender identity, sexuality, or related issues
m)Psychosis/Schizophrenia, borderline personality
/ K, PC, IPC, SBP
- Serve as case manager or active team participant for individuals with developmental and behavioral disorders through the primary care setting, demonstrating skills including, but not limited to:
a)Communication and record-sharing with other disciplines
/ IPC
b)Maintenance of a complete problem list
/ IPC
c)Managing the "whole patient"
/ PC, P
d)Family empowerment and communication
/ P, IPC
e)Maintain patient and family confidentiality (HIPAA)
/ P
- Discuss interventions and specialists that assist with the diagnosis or ongoing management of children with developmental-behavioral disorders, demonstrate knowledge of referral sources, and demonstrate ability to work collaboratively with a variety of these professionals.
b)Behavior modification specialists
c)Child Life
d)Child psychiatry
e)Child psychology
f)Community resources/support systems (Boys and Girls club, Family Resource Centers)
g)Developmental-behavioral pediatrician
h)Early intervention services
i)Educational intervention (preschool and school age)
j)Family counseling
k)Feeding specialists
l)Hypnosis, relaxation, and self-control techniques
m)Interdisciplinary team for evaluation
n)Neurodevelopmental pediatrician
o)Pediatric neurology
p)Occupational therapy
q)Physical therapy
r)Physical medicine and rehabilitation
s)Pharmacotherapy
t)Social work services
u)Speech and language therapy
v)Teachers and other school staff
w)Vision specialist
x)Other (play therapy, music therapy, support groups, parent training, etc.)
/ K, PC, IPC, P
GOAL V: Attention Deficit Hyperactivity Disorder. Diagnose and manage uncomplicated cases of ADHD and refer refractory cases.
- Develop a differential diagnosis for the symptoms of hyperactivity and/or inattention.
- Interpret parent, teacher and patient information (history and questionnaires) that documents symptoms of ADHD and co-morbid conditions.
- Use DSM-PC or DSM criteria to diagnose ADHD.
- Explain to parents the issues surrounding the diagnosis, with implications for medications and other therapies, and impact on family and school life.
- Initiate appropriate pharmacotherapy, monitoring for therapeutic effect of medication as well as side effects. Use ongoing feedback from parents and teachers to make appropriate changes in medication, consider additional therapy and/or reconsider the possibility of co-morbid conditions not originally diagnosed.
- Understand the indications for referral for behavior therapy and appropriately refer.
- Recognize co-morbid conditions (e.g., depression, bipolar disorder, anxiety, cognitive problems, learning disabilities) and refer when appropriate.
- Continuously monitor and follow-up patients with ADHD. Obtain periodic information in standardized form (questionnaires) from parents and teachers to evaluate progress. Identify when changes in current medication regimen are indicated.
- Work with the family and schools to optimize school success and self-esteem.
GOAL VI: Depression. Understand the pediatrician's role in screening, diagnosing, managing and/or referring children and parents with depression.
- Identify family history of mood disorders and other psychiatric conditions to enhance identification of children with these disorders.
- Recognize the differences in presentation of depression and other mood disorders during the developmental course of childhood.
- Assess environmental contributors to the development of mood disorders (abuse, neglect, family psychiatric symptoms).
- Screen for anxiety and depression at all appropriate health maintenance visits, including early childhood.
- Recognize vegetative and non-specific symptoms that may be due to depression (e.g., sleep disturbances, irritability, anhedonia, hopelessness, isolation).
- Screen and monitor carefully for signs of potential suicidal behavior.
- Consider the initiation of appropriate pharmacologic interventions for children with uncomplicated depression. Demonstrate familiarity with the pharmacologic treatment of depression (e.g., SSRIs).
- Refer for psychotherapy and collaborate with the mental health provider in monitoring clinical course.
GOAL VII: Developmental Disabilities/Mental Retardation. Understand the pediatrician's role in screening, diagnosing, managing and/or referring children with developmental disabilities and mental retardation.
- Generate a differential diagnosis for the child with persistent global developmental delay, persistent motor delays, with abnormalities in speech and language development, and with persistent learning difficulties.
- Coordinate an evaluation of a child with persistent developmental symptoms.
- Know the effects that developmental disabilities have on child and family functioning and how to assist with them.
- Know the common medical complications associated with the more common developmental disabilities such as cerebral palsy, mental retardation, Down's syndrome and meningomyelocele.
- Know effective therapies available for children with cerebral palsy, mental retardation, genetic disorders and meningomyelocele.
- Coordinate comprehensive care for children with cerebral palsy, various degrees of mental retardation, genetic disorders and meningomyelocele.
GOAL VIII: Oppositional Defiant Disorder. Understand the pediatrician's role in screening, diagnosing, managing and/or referring children with oppositional defiant disorder.
- Generate a differential diagnosis for children presenting with negative emotional behaviors, aggressive emotional behaviors, and secretive or antisocial emotional behaviors.
- Discuss the physiological (temperament) and environmental antecedents of negative or antisocial behavior patterns.
- Devise an evaluation and intervention strategy for a child exhibiting negative or antisocial behavior.
- Counsel families of children with milder forms of negative or antisocial behavior and monitor the effectiveness over time.
- Determine when a child with negative/antisocial behavior needs to be referred to appropriate professionals and community resources and continue to participate in the child's ongoing primary care.
GOAL IX: Autistic Spectrum Disorders. Understand the pediatrician's role in screening, diagnosing, managing and/or referring children with autism spectrum disorders.
- Use history and observation to identify children with social interaction difficulties and communication impairments.
- Recognize developmental milestone red flags for autism spectrum disorders (e.g., absence of joint attention by 9-12 mo of age, absence of pretend play by 18 mo of age, language delays).
- Generate a differential diagnosis for ASD.
- Screen and refer identified children with the possibility of ASD.
- Be familiar with appropriate long-term management techniques and necessary components of an effective educational and habilitation program for children with autism spectrum disorders.
Core Competencies:K - Medical Knowledge
PC -Patient Care
IPC -Interpersonal and Communication Skills
P -Professionalism
PBLI -Practice-Based Learning and Improvement
SBP - Systems-Based Practice
Performance Expectations by Level of Training
Beginning / Developing / Accomplished / CompetentDescription of identifiable performance characteristics reflecting a beginning level of performance. / Description of identifiable performance characteristics reflecting development and movement toward mastery of performance. / Description of identifiable performance characteristics reflecting near mastery of performance. / Description of identifiable performance characteristics reflecting the highest level of performance.
Medical Knowledge / PL1 / PL1, PL2 / PL2, PL3 / PL3
Patient Care / PL1 / PL1, PL2 / PL2, PL3 / PL3
Interpersonal and Communication Skills / PL1 / PL1, PL2 / PL2, PL3 / PL3
Professionalism / PL1 / PL2, PL3 / PL3
Practice-Based Learning and Improvement / PL1 / PL1, PL2 / PL2, PL3 / PL3
Systems-Based Practice / PL1 / PL1, PL2 / PL2, PL3 / PL3
PC1. Gather essential and accurate information about the patient
Level 1 / Level 2 / Level 3 / Level 4 / Level 5
Either gathers too little information or exhaustively gathers information following a template regardless of the patient's chief complaint, with each piece of information gathered seeming as important as the next. Recalls clinical information in the order elicited, with the ability to gather, filter, prioritize, and connect pieces of information being limited by and dependent upon analytic reasoning through basic pathophysiology alone / Clinical experience allows linkage of signs and symptoms of a current patient to those encountered in previous patients. Still relies primarily on analytic reasoning through basic pathophysiology to gather information, but has the ability to link current findings to prior clinical encounters allows information to be filtered, prioritized, and synthesized into pertinent positives and negatives, as well as broad diagnostic categories / Demonstrates an advanced development of pattern recognition that leads to the creation of illness scripts, which allow information to be gathered while simultaneously filtered, prioritized, and synthesized into specific diagnostic considerations. Data gathering is driven by real-time development of a differential diagnosis early in the information- gathering process / Creates well-developed illness scripts that allow essential and accurate information to be gathered and precise diagnoses to be reached with ease and efficiency when presented with most pediatric problems, but still relies on analytic reasoning through basic pathophysiology to gather information when presented with complex or uncommon problems / Creates robust illness scripts and instance scripts (where the specific features of individual patients are remembered and used in future clinical reasoning) that lead to unconscious gathering of essential and accurate information in a targeted and efficient manner when presented with all but the most complex or rare clinical problems. These illness and instance scripts are robust enough to enable discrimination among diagnoses with subtle distinguishing features
PC2. Organize and prioritize responsibilities to provide patient care that is safe, effective, and efficient
Level 1 / Level 2 / Level 3 / Level 4 / Level 5
Struggles to organize patient care responsibilities, leading to focusing care on individual patients rather than multiple patients; responsibilities are prioritized as a reaction to unanticipated needs that arise (those responsibilities presenting the most significant crisis at the time are given the highest priority); even small interruptions in task often lead to a prolonged or permanent break in that task to attend to the interruption, making return to initial task difficult or unlikely / Organizes the simultaneous care of a few patients with efficiency; occasionally prioritizes patient care responsibilities to anticipate future needs; each additional patient or interruption in work leads to notable decreases in efficiency and ability to effectively prioritize; permanent breaks in task with interruptions are less common, but prolonged breaks in task are still common / Organizes the simultaneous care of many patients with efficiency; routinely prioritizes patient care responsibilities to proactively anticipate future needs; additional care responsibilities lead to decreases in efficiency and ability to effectively prioritize only when patient volume is quite large or there is a perception of competing priorities; interruptions in task are prioritized and only lead to prolonged breaks in task when workload or cognitive load is high / Organizes patient care responsibilities to optimize efficiency; provides care to a large volume of patients with marked efficiency; patient care responsibilities are prioritized to proactively prevent those urgent and emergent issues in patient care that can be anticipated; interruptions in task lead to only brief breaks in task in most situations / Serves as a role model of efficiency; patient care responsibilities are prioritized to proactively prevent interruption by routine aspects of patient care that can be anticipated; unavoidable interruptions are prioritized to maximize safe and effective multitasking of responsibilities in essentially all situations
PC4. Make informed diagnostic and therapeutic decisions that result in optimal clinical judgment
Level 1 / Level 2 / Level 3 / Level 4 / Level 5
Recalls and presents clinical facts in the history and physical in the order they were elicited without filtering, reorganization, or synthesis; demonstrates analytic reasoning through basic pathophysiology results in a list of all diagnoses considered rather than the development of working diagnostic considerations, making it difficult to develop a therapeutic plan / Focuses on features of the clinical presentation, making a unifying diagnosis elusive and leading to a continual search for new diagnostic possibilities; largely uses analytic reasoning through basic pathophysiology in diagnostic and therapeutic reasoning; often reorganizes clinical facts in the history and physical examination to help decide on clarifying tests to order rather than to develop and prioritize a differential diagnosis, often resulting in a myriad of tests and therapies and unclear management plans, since there is no unifying diagnosis / Abstracts and reorganizes elicited clinical findings in memory, using semantic qualifiers (such as paired opposites that are used to describe clinical information [e.g., acute and chronic]) to compare and contrast the diagnoses being considered when presenting or discussing a case; shows the emergence of pattern recognition in diagnostic and therapeutic reasoning that often results in a well- synthesized and organized assessment of the focused differential diagnosis and management plan / Reorganizes and stores clinical information (illness and instance scripts) that lead to early directed diagnostic hypothesis testing with subsequent history, physical examination, and tests used to confirm this initial schema; demonstrates well-established pattern recognition that leads to the ability to identify discriminating features between similar patients and to avoid premature closure; Selects therapies that are focused and based on a unifying diagnosis, resulting in an effective and efficient diagnostic work-up and management plan tailored to address the individual patient / Current literature does not distinguish between behaviors of proficient and expert practitioners. Expertise is not an expectation of GME training, as it requires deliberate practice over time