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Developmental & Behavioral: Children with Special Health Care Needs (CSHCN)

Medical Director: Sarah Winter, MD


Working knowledge of typical development and behavior to differentiate normal from abnormal states:

  • Describe spectrum of normal development and variations for typical children
  • Identify major theories of development
  • Discuss how different behavioral and developmental domains interact and influence one another
  • Counsel families on variations in typical development and behavior
  • Identify red flags of abnormal development and behavior
  • Counsel parents about typical parenting issues
  • Recognize and differentiate developmentally appropriate and inappropriate coping strategies children use to contend with illness and medical interventions

Awareness of the purposes, limitations, and indications for formal screening and psycho-educational testing:

  • Understand the pediatrician's role in evaluation and management of school performance issues
  • Differential diagnosis, preliminary evaluation within the medical home, and referral strategies
  • Identification, treatment and/or referral of medical and mental health conditions that contribute to school problems
  • Understand the collaborative role with the educational system, mechanisms that drive provision of special education services within the school system (IEP, 504 plan, health plans, home bound education) and the role of various school professionals (school psychologist, school nurse, 504 coordinator)
  • Understand the role of other health and allied professionals who may be involved in the evaluation of the child with school performance issues (e.g. psychologists, neuropsychologists)
  • Be familiar with the use of rating scales that may be used in the home as part of an evaluation of school difficulties (e.g. Vanderbilt Scales, depression scales, CBCL)Provide information and support to parents
  • Awareness of standardized/validated measures and interviews to identify patterns of atypical development
  • Demonstrate working knowledge of psycho-educational testing tools, results, and interpretations

Understand the role of the pediatrician in prevention of developmental and behavioral problems in children:

  • Describe common influences that promote - and interfere with - optimal development and behavior

Provide appropriate anticipatory guidance related to common developmental and behavior issues:

  • Describe expected behaviors and milestones as a child's next developmental level
  • Provide anticipatory guidance, developmental promotion, and counseling for common issues

Evaluate and manage common developmental and behavioral signs and symptoms in infants, children, and adolescents:

  • Perform an appropriate problem-oriented interview and physical examination
  • Formulate a plan for evaluation (information from other sources and structured screening)
  • Formulate a differential diagnosis
  • Develop a management plan with family
  • Evaluate and manage common developmental and behavior signs and symptoms

Recognize and manage common conditions not requiring a referral:

  • Discuss environmental and biologic risk factors
  • Explain alternative co-morbid conditions
  • Describe natural history and common variations
  • Implement primary care case assessment
  • Counsel parents in age-appropriate interventions
  • Execute appropriate referrals

Recognize and provide initial management and referral of more complex developmental and behavioral conditions needing additional diagnostic or management support:

  • Describe diagnostic criteria, environmental and biologic risks, alternative and co-morbid conditions, and natural history
  • Serve as case manager or active team participant for individuals with developmental and behavioral disorders through the primary care setting
  • Discuss interventions and specialists that assist with the diagnosis or ongoing management of children with developmental and behavioral disorders, demonstrate knowledge of referral sources, and demonstrate ability to work collaboratively with a variety of these professionals
  • Understand the pediatrician's role in screening, diagnosing, managing, and/or referring children with neurodevelopmental disabilities (e.g. cognitive impairment, CP, Trisomy 21, spina bifida, and syndromic conditions)

Recognize and manage patients with conditions affecting neurodevelopmental function which generally require referral:

  • Evaluate, treat, and/or refer children with presenting signs and symptoms that may indicate conditions affecting neurodevelopmental function
  • Develop management strategies for children with developmental disabilities within the context of the medical home
  • Identify co-morbid conditions (e.g. medical, sensory, mental health) with strategies for evaluation, treatment and/or referral
  • Coordination of care including community resources (school, home health, allied health, and durable medical equipment)
  • Identify specific information to educate parents on NDD, its natural course, and impact
  • Understand relevant health care funding (e.g. Medicaid waivers and medical necessity), legal eligibility issues (e.g. guardianship and educational rights), and concepts including medical home, family centered care, and transition
  • Recall medications used for behavioral management in children with NDD
  • Discuss common neurosurgical, bowel/bladder, cognitive, and other medical issues common in children with spina bifida
  • Discuss screening recommendations and common complicating medical concerns for children with Trisomy 21
  • Discuss and evaluate common complicating issues for children with cerebral palsy (e.g. malnutrition, tone abnormalities, orthopedic complications, constipation, chronic lung disease, GERD, and aspiration)
  • Increase awareness of subacute care settings in the role of transitional care, family training, respite support, and long term care
  • Enhance awareness of the unmet dental needs of this population and resources for care

Understand the pediatrician's role in screening, diagnosing, managing, and/or referring children with speech, language, and communication disorders (e.g. hearing impairment, speech disorders, language delays, and autism spectrum disorders):

  • Identify children with social and communication difficulties
  • Identify developmental milestones and red flags
  • Practice screening, differential diagnosis, and coordination of evaluation
  • Coordinate allied health professionals (audiology and therapy services), mental health services, and community resources (psychology, early intervention, school resources)
  • Provide information and support for parents
  • Describe basic strategies for ASD
  • Raise awareness of mental health issues that may complicate ASD (e.g. anxiety)

Understand how pediatricians can prevent conditions that affect development and neurologic function in children, and in screening individuals at risk for NDD:

  • Raise awareness of state and federal programs and clinicians’ roles as advocate
  • Raise awareness of the long term outcomes of high risk infants (e.g. low birth weight, premature, and substance exposed)

Distinguish normal from pathologic conditions affecting neurodevelopmental functions in children:

  • Identify normal nervous system development and variation in child developmental patterns
  • Recognize findings indicating NDD
  • Give developmental assessments
  • Give neurologic exam
  • Assess language and social interaction, and hearing

Tests and procedures:

  • Describe common procedures including how they work and when they should be used
  • Administer ADHD home and school questionnaires
  • Administer behavioral screening questionnaires
  • Administer developmental and language screening tests
  • Administer Capute Scales (CAT/CLAMS)

Optional Objectives:

Residents also have the opportunity to support specialists and assist with management of children with developmental and behavioral difficulties. Optional objectives may include:

  • Increasing awareness of referral resources, roles, and duties for specialty care providers for children with chronic illness/disease, including: audiologists, behavior modification specialists, child life, family counseling, feeding specialists, neurodevelopmental pediatricians, OT, PT, PM&R, social work and vision specialists
  • Providing anticipatory guidance to families about the developmental aspects of common issues
  • Gaining experience providing guidance regarding: injury prevention, adoption, children at environmental risk, day care, death, divorce, exposure to violence, alternative parenting environments, sexuality, sibling rivalry, television, study, and literacy skills, and more