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Developmental Behaviorial Pediatrics

Welcome to the Rotation in Developmental Behavioral Pediatrics

This rotation is an opportunity to expand your understanding of developmental-behavioral and psychosocial issues, particularly those that impact on your professional interests. We aim to combine a traditional approach to training with more learner-centered models of education so that your experience exposes you to the basics of child development and also addresses your individualized interests.

Core activities include:

• Hands on clinical experiences
• Targeted observation activities
• Community experiences
• Didactics
• Developmental Behavioral Peds seminar
• Mentored learning experiences
• Case-based learning
• Independent learning activities

Your schedule and directions to all activities is posted on the web. If you cannot make any of the scheduled activities please call the site you are scheduled for to let them know. If the schedule is incorrect, please alert Annmarie Healy at 785-3898.

We have developed a bibliography of important Developmental-Behavioral Pediatrics articles for your library. Before you meet with Dr. Avni-Singer, please read Chapters 2 and 3 from Encounters with Children. This can be found under the "Family Communications" heading on the Reading Articles page. The articles you will need to read to prepare for and to execute the germ talk are under the heading "Germ Talk", also on the Reading Articles page.

Listed below are descriptions of modules that require some planning on your part for them to be successful and interesting. Please read these sections carefully.

DBP Rotation Highlights

• Doctor-Patient Communication and Young Children’s Social-Emotional Development
• Motivational Interviewing
• Benhaven
• Parenting 101
• Autism Clinic

Doctor-Patient Communication and Young Children’s Social-Emotional Development

Mandatory Readings: Chapters 1, 2 and 3 in Encounters with Children

Goals and Objectives:

Goal: To develop knowledge and competency in understanding and assessing emotional development in young children.

Objective 1: Residents will learn about different theoretical constructs including Erickson’s stages and Attachment theory. Each resident will then videotape at least one well child visit for review with a faculty member. Satisfying this goal will improve core competencies in:

• Patient Care by learning to use observations of child behavior and parent-child interaction to make inferences on the child’s emotional development. The resident will practice discussing these observations with parents during the visit.
• Medical Knowledge: Residents will develop a greater understanding of the influence of the quality of early relationships in the development of emotional health and social competence.
• Interpersonal and Communication Skills Residents will have a greater knowledge of how to create a therapeutic alliance with families through developing feelings of trust, openness and empathy.

Residents will meet with Dr. Avni-Singer twice during the rotation to understand the impact of early childhood social-emotional development on future developmental and behavioral outcomes and consider new strategies to enhance communication with parents on this topic. As part of that experience, residents will be asked to videotape themselves during their continuity clinic. This is meant to be an educational, not evaluative experience and videotapes will only be viewed by the residents on rotation at that time and Dr. Avni-Singer. On the first session, Dr. Avni-Singer will explain more about the goals of this experience. Annmarie Healy has the cameras and you can sign them out through her.

Motivational Interviewing

Mandatory Readings:

• Brief Motivational Interviewing as a Clinical Strategy to Promote Asthma Medication Adherence. Borelli, et al., J Allergy Clin Immunol, November 2007.
• Training General Practitioners in Behavior Change Counseling to Improve Asthma Medication Adherence. Broers et al., Patient Education and Counseling, 58 (2005) 279–287.

Goals and Objectives:

Residents will meet with Dr. Stahl twice during the rotation to become familiar with motivational interviewing and of its potential uses within pediatric primary care. Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Key to this process rests in the understanding that motivation to change is elicited from the client, and is not imposed. Motivational Interviewing is not meant to be a form or coercion or persuasion but an opportunity for parents to examine barriers and facilitators of change along with their doctor. It is a powerful tool that can strengthen parents’ abilities to care for their children effectively.

Benhaven

Mandatory Readings: Health Care for Individuals with Developmental Disabilities

Goals and Objectives:

Goal: To have a greater knowledge of community resources for children with autism and other developmental disabilities.

Objectives:

1. Residents will visit Ben Haven, a local school and residential program for older children and adolescents with autism and cognitive disabilities. They will attend a multidisciplinary case review at the residence or a didactic training for educators at the school.
2. Satisfying this goals will improve core competencies in:
   • Systems Based Practice as residents will have a greater understanding of the diversity of systems involved in providing care for children with developmental disabilities and a greater understanding of how these systems integrate physical and mentalhealth care with educational services to meet the complex needs of these children. In addition, residents will have a greater knowledge of how to collaborate with other providers of care to children.
   • Medical knowledge: Residents will learn about the atypical ways that patients with autism and severe cognitive impairment present when they have common medical problems such as GERD, sinus infections or UTIs.

Residents will have an opportunity during this rotation to attend team rounds with Dr. Avni-Singer at Benhaven, a residential facility for children with Autism who are significantly impaired. It’s an opportunity to understand the range of complexities in caring for children with significant developmental disabilities and the role a pediatrician can play in consulting to a center.

Parenting 101

Mandatory Readings: Chapters 1, 2 and 3 in Encounters with Children

Goals and Objectives:

Observation Forms

Knowing how to counsel parents effectively rests on understanding their concerns, hearing their stories and becoming more facile observers of the parent, the child and their interactions. What better place than in the laboratory (the well-child visit) before you?

During this rotation, on as many occasions as you can, go somewhere where parents and kids hang out (supermarkets, malls, playgrounds, etc.) On the enclosed form, note SPECIFIC behaviors that you observe to promote positive connection between parents and children and SPECIFIC behaviors that interfere. DON'T INTERPRET THE BEHAVIORS YET, JUST DESCRIBE THEM. Being specific means reporting — Mother bent down to be at eye level with the child vs. Mother was nice to the baby. Look for a range of interactions, both positive and negative.

Next, when you have finished your observations and feel you have gained some insight about promoting positive parent-child relations, go to the next page and create a summary list of what you think parents can do to create a positive interaction with their child.

Lastly—on the third page—practice seeing what it’s like to talk about this during a well child visit in a way that is different from your current practice. Use some techniques gained through the Motivational Interviewing and the sessions with Dr. Avni-singer. Use your observations of the parent, the child and the interactions to narrate positive moments and explore difficult ones.

Autism Clinic

Mandatory Readings:

• Identification and Evaluation of Children With Autism Spectrum Disorders
• Management of Children With Autism Spectrum Disorders

Review prior to attending: Insert Observation Guidelines

Goals and Objectives:

The section of the rotation in Developmental-Behavioral Pediatrics on learning about autism spectrum disorders (ASDs) and observing the autism clinics at the Child Study Center has the following goals and objectives:

Goal: To become familiar with the diagnostic criteria for ASDs and the differential diagnosis for children presenting with a possible ASD.

Objectives:

1. Residents will learn about the various components of the history and assessment that contribute to the overall clinical impression of ASD. For two patients at the Child Study Center autism clinics, they will observe the caregiver interview for developmental history, IQ and speech/language testing, and the Autism Diagnostic Observation Schedule (ADOS).
2. Satisfying this goal will improve core competencies in:
   • Medical knowledge: Residents will develop a greater understanding of the wide range of phenotypes that is possible in ASD.
   • Patient care: Residents will have greater recognition of the warning signs of ASD among children in their practice.

Goal: To learn about the medical assessment of children with ASD.

Objectives:

1. Residents will learn when additional diagnostic tests are indicated in children with ASD, such as genetics, EEG, and imaging studies.
2. Satisfying this goal will improve core competencies in:
   • Patient care: Residents will learn which laboratory tests they should consider ordering for patients in their practice with ASD.
   • Systems-based practice: Residents will learn the appropriate use of additional diagnostic tests to avoid ordering tests that are currently considered to be of low yield in ASD.

Goal: To become familiar with the treatment plans for children with ASD.

Objectives:

1. Residents will learn about the medical, educational, and behavioral interventions commonly employed for children with ASD by attending the clinical team feedback sessions.
2. Satisfying this goal will improve core competencies in:
   • Patient care: Residents will learn about the medications which are often used to treat maladaptive behaviors in ASD and of which they may help monitor the efficacy and side effects. Residents will learn about the educational and behavioral therapies that may be recommended for their patients and which they may need to advocate for on their patients’ behalf.
   • Interpersonal and communication skills: Residents will become familiar with the large and diverse multidisciplinary team which often follows these patients and their role within that team.

This rotation presents an excellent opportunity to observe diagnostic evaluations in the Yale Developmental Disabilities clinic and to participate in a multidisciplinary evaluation. The multidisciplinary team conducts evaluations that consist of psychological and developmental testing, psychiatric assessment and a speech, language and communication evaluation. At the conclusion of the assessment, prior to meeting with the family, the team will meet to discuss the results of the evaluation and recommendations for intervention.

Independent Learning Activities

There are a number of components to the independent learning activities. Begin by identifying an area of child behavior and development of interest. If you are not going into general pediatrics, try to identify a topic that pertains to your subspecialty. During the rotation, accomplish the following goals:

• What are the kids reading? Read a book relevant to your topic that is aimed at kids and critique it*. Use your public library for this. If you can't find ANYTHING let me know and we will see if we can help to get a book.
• What are the parents reading? Read a book relevant to your topic that is aimed at parents and critique it*.
  

  *Please submit a completed review of the book you've read that was aimed at kids or parents. DBP Book Review Form

  Go to BOOK REVIEWS

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• Complete at least three modules in the Developmental & Behavioral Pediatrics Training Modules for Clinical Issues in Primary Care. Choose the cases that are of most interest to you. Annmarie Healy has the discs for this. Please be prepared to discuss them and offer your critique.
• Attend a parent support group relevant to your topic if you can find one or attend a parent support group for anything related to child behavior and development. (There is a list of potential groups to attend on the next page.) If you find a new group or one of the listed groups doesn't exist anymore, or is not good, etc., please let me know.
• Conduct a literature search and summarize your findings and conclusions in a 45-minute presentation at the end of the month in DBP conference.

Please complete the Independent Learning Activities Checklist and return to Dr. Weitzman at the end of the rotation.

Parent Support Groups

• Downloadable PDF of available Parent Support Groups
• Please call in advance to confirm that the group is happening at the stated time. These groups are a bit of an unknown entity.
• Explain who you are and obtain permission to attend. (I can provide a letter of introduction to fax to them.)
• If you go to a new group, please forward contact and information to Carol Weitzman so it can be added to the list.
• Please write a thank you note after the visit if applicable.