New Application: Developmental Behavioral Pediatrics
Review Committee for Pediatrics
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
COMMON SUBSPECIALTY SECTION
FACULTY RESEARCH
1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary.
[PR II.B.5.b)]
# of current
IRB approved
research
Name
projects
Program Director:
Total # of
current
funded
research
projects
# of current
research
projects with
peer review
funding
(subset of
total # in
previous
column)
#
presentations
at national
scientific
# publications
meetings in in peer review
the last 5
journals in the
years
last 5 years
Key Faculty:
Research Mentors Who Are Not Key Faculty:
2. List active research projects in the subspecialty. Add additional rows as necessary.
Project title
Funding
source
Put an “X” for
funding
awarded by
peer review
process
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Years of
funding
(dates)
Faculty investigator and
role in grant (i.e. PI, Co-PI,
Co-investigator)
Updated 4/2015
Page 1 of 12
RESEARCH RESOURCES
1. Does the program provide research laboratory space and equipment? (if appropriate) [PR II.D.]
.................................................................................................................................... ☐ YES ☐ NO
2. Does the program provide financial support for research? ........................................... ☐ YES ☐ NO
3. Does the program provide computer and statistical consultation services? .................. ☐ YES ☐ NO
PROGRAM CURRICULUM
Goals and Objectives
Place an ‘X” in the box before the applicable response. [PR IV.A.2.]
Are there goals and objectives for all training
☐ YES ☐ NO
experiences?
Are they rotation and level specific?
☐ YES ☐ NO
How are they distributed?
☐ Hard Copy ☐ Electronic or web-based
If not web-based, when are they distributed to
☐ Prior to Each Rotation
☐ Annually
fellows?
☐ Once in Handbook
☐ Other
If not web-based, when are they distributed to
☐ Prior to Each Rotation
faculty?
☐ Annually
☐ Other
If web-based, do you send out reminders to access ☐ YES ☐ NO
them?
If yes, when do you send them?
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Collaboration between Programs
Are there meetings among the core Program
Director and subspecialty Program Directors?
How often do these meetings occur?
Who is typically involved in these meetings?
(check all that apply)
☐ YES ☐ NO
Click here to enter text.
☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties
General Subspecialty Curriculum
Topic
e.g., Biostatistics
Basic science as
related to the
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Research
Course
14
X
Click here to
Click here to enter
☐
☐
☐
enter text.
text.
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 2 of 12
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Topic
application in clinical
subspecialty practice
Clinical subspecialty
Click here to
#
☐
☐
☐
content
enter text.
For the topics below, if the topic is not appropriate for your discipline (i.e., lab research for
fellows in developmental and behavioral pediatrics), enter N/A into column 1.
Biostatistics
Click here to
#
☐
☐
☐
enter text.
Lab research
Click here to
#
☐
☐
☐
methodology (if
enter text.
appropriate)
Clinical research
Click here to
#
☐
☐
☐
methodology
enter text.
Study design
Click here to
#
☐
☐
☐
enter text.
Grant preparation
Click here to
#
☐
☐
☐
enter text.
Preparation of
Click here to
#
☐
☐
☐
protocols for
enter text.
institutional review
board
Principles of evidence- Click here to
#
☐
☐
☐
based medicine/
enter text.
Critical literature
review
Quality Improvement Click here to
#
☐
☐
☐
enter text.
Teaching skills
Click here to
#
☐
☐
☐
enter text.
Professionalism/Ethics Click here to
#
☐
☐
☐
enter text.
Cultural Diversity
Click here to
#
☐
☐
☐
enter text.
Systems-based
Click here to
#
☐
☐
☐
practice (economics of enter text.
healthcare, practice
management, clinical
outcomes, etc.)
Conferences
1. List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the
subspecialty training program. Identify the "SITE" by using the corresponding number as appears
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 3 of 12
on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and
whether conference attendance is required (R) or optional (0). List the planned role of the fellow in
this activity (e.g., conducts conference, presents case and participates in discussion, case
presentation only, participation limited to Q&A component, etc.). Add rows as necessary.
Conference
Site #
Frequency
R/O
Role of the Fellow
2. Describe the mechanism that will be used to ensure fellow attendance at required conferences.
State the degree to which faculty attendance is expected, and how this will be monitored.
Limit the response to 50 words
Click here to enter text.
Scholarship Oversight Committee
1. Will there be a scholarship oversight committee for every fellow? ................................ ☐ YES ☐ NO
2. How often will the committee meet with the fellow? ............................................... [ # ] times per year
Fellow Research Activities
1. Describe how the program will ensure a meaningful supervised research experience for the fellows,
beginning in their first year and extending throughout their training.
Click here to enter text.
2. If faculty outside the division will be actively involved in mentoring the fellows, identify the mentors
and describe how liaisons will be created between these mentors and the fellows that allows for
meaningful accomplishment of research.
Click here to enter text.
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 4 of 12
SPECIALTY-SPECIFIC SECTION
PROGRAM PERSONNEL AND RESOURCES
Other Program Personnel [PR VII.B.1.]
1. Indicate with a check mark the personnel who will interact regularly with fellows at each
participating site.
Team Members
Occupational Therapy
Physical Therapy
Social work
Speech and Language Pathology
Audiology
Childhood Education
Public Health
Site #1
☐
☐
☐
☐
☐
☐
☐
Site #2
☐
☐
☐
☐
☐
☐
☐
Site #3
☐
☐
☐
☐
☐
☐
☐
2. For categories of personnel that are unavailable, describe how that function will be addressed in the
program.
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Facilities/Training Sites and Services [PR VII.C.]
1. Indicate the availability of the following:
Facility/Service
Space in an ambulatory setting for optimal
evaluation and care of patients (as described in
Program Requirements)
Opportunities for collaboration with General
Pediatric Service [PR VII.C.3.]
Site #1
(Yes/No)
Choose an
item.
Site #2
(Yes/No)
Choose an
item.
Site #3
(Yes/No)
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
2. For each facility, indicate (use additional pages as necessary):
a) who is directly responsible for patient care and
b) the planned role of the fellow in that care
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Community Based [PR VII.C.4]
Identify the community-based resources, such as child care programs, early intervention programs,
schools, and child welfare/protective agencies the fellows will utilize.
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 5 of 12
Community Based
Resources
Child care programs
Early intervention
programs
Schools
Child welfare/protective
agencies
Community agencies
that serve children who
have visual or hearing
impairments, mental
health conditions or
developmental, physical
or emotional disabilities:
Name of Setting
(Include all sites
for fellows’
longitudinal
experience).
Designate
longitudinal sites
with an asterisk
(*).
Name
Name
Planned Role of Fellow in
Care of Patients –
Designate as: Primary
Provider (PP)
Consultant (C)
Observer (O)
Frequency
Multidisciplinary Care
of
Team Member (T)
Interaction
Counselor (CS)
Frequency
Choose an item.
Frequency
Choose an item.
Type of
Interaction
Type
Type
Name
Name
Type
Type
Frequency
Frequency
Choose an item.
Choose an item.
Name
Type
Frequency
Choose an item.
Patient Data
Provide the following information for the most recent 12-month academic or calendar year. Note the
same timeframe should be used throughout the forms.
Inclusive dates:
FROM: Click here to enter a date.
Outpatient: Provide the Name of
each Clinical Site
1. Is there a separate
Developmental-Behavioral
Pediatrics clinic?
2. Number of DevelopmentalBehavioral Pediatrics clinic/or
office sessions per week during
12-month period reported:
3. Number of ambulatory
Developmental-Behavioral
Pediatrics visits during the 12month period reported:
4. Estimated number of new
patients or new encounters that
will be seen by the fellows
during a 12-month period:
TO: Click here to enter a date.
Name
Name
Name
Name
Name
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
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#
EDUCATIONAL PROGRAM [PR VIII.]
12-Month Summary: Inpatient Services/Outpatient Clinics [PR VIII.A.1.b).(1)]
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 6 of 12
During the same 12-month period as used on the previous sections, list below the numbers of pediatric
patients who were:
a) seen in all ambulatory settings (not just Developmental-behavioral pediatrics clinic);
b) admitted to and/or consulted on by the Developmental-Behavioral Pediatrics specialists at the
primary site, if applicable.
Count only new patients or new encounters. Multiple visits by the same patient should not be counted.
A new encounter may occur when a patient, who may be known to the service and, therefore, not be a
new patient, is now being hospitalized and a consultation is requested. Insert additional pages as
needed.
Developmental Behavioral Pediatrics
Cognitive disabilities [PR VIII.B.2.f)]
Language and learning disorders [PR VIII.B.2.g)]
Motor disabilities (e.g., cerebral palsy,
myelodysplasia, dystrophies) [PR VIII.B.2.h)]
Autism, Asperger’s syndrome, autistic spectrum
disorder [PR VIII.B.2.i)]
Attention disorders [PR VIII.B.2.j)]
Externalizing conditions (e.g., aggressive behavior,
conduct disorder, oppositional defiant disorder) [PR
VIII.B.2.k)]
Internalizing behaviors (e.g., anxiety, mood, and
obsessive disorders, suicidal behavior)
[PR VIII.B.2.l)]
Substance use/abuse e.g., tobacco, alcohol, illicit
drugs as a co-morbidity of developmental and
behavioral disorders [PR VIII.B.2.m)]
Child abuse and neglect, (e.g., physical, sexual,
factitious) as it impacts children with developmental
behavioral disorders; developmental behavioral
sequelae of child abuse and neglect [PR
VIII.B.2.n)]
Issues arising from family structure [PR VIII.B.2.o)]
Somatoform conditions [PR VIII.B.2.p)]
Sleep disorders [PR VIII.B.2.q)]
Feeding/eating difficulties associated with
developmental behavioral disorders (e.g., obesity,
failure to grow, oral aversion, picky eating, oralmotor problems) [PR VIII.B.2.r)]
Elimination problems (e.g., encopresis, enuresis)
[PR VIII.B.2.s)]
Atypical behaviors (e.g., tic disorders, self-injurious
behavior, repetitive behaviors) [PR VIII.B.2.t)]
# of New Outpatient
Patients/Encounters*
#
#
#
# of New Inpatient
Consults
#
#
#
#
#
#
#
#
#
#
#
#
#
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List of Diagnoses
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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List 150 CONSECUTIVE consultations/encounters in which fellows were engaged with the
Developmental-Behavioral Pediatrics service or 3 months of data from each clinic or clinical site in the
Developmental-Behavioral Pediatrics outpatient service. Identify the time period during which these
consultations/encounters occurred. The date range should occur within the same 12-month period used
in previous sections. The dates must begin on the date the first patient encounter on the list and end
with the date of the 150th patient encounter, (e.g., July 1, 2014 through October 20, 2014). Submit a
separate list for each clinical site that provides required rotations. Duplicate tables as necessary.
Clinical Site:
Inclusive dates:
FROM: Click here to enter a date.
Patient ID
Number
Age
TO: Click here to enter a date.
Developmental-Behavioral Pediatrics Diagnosis
(may include secondary diagnosis if relevant)
Core Curriculum: Specialty Experiences
Identify the learning activities (clinical experience, conference series, etc.) and training sites (Site # or
clinic) which will be used to address the required core knowledge areas listed below:
List the Learning Activities
Used to Address the Core
Knowledge/Skills
Core Medical Knowledge
Biological mechanisms of
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behavior and development,
e.g., development and
functional organization of the
central nervous system,
neurophysiology, genetics,
and biological risk factors
[PR VIII.B.2.a)]
Family and social/cultural
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factors that contribute to
children’s development and
Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
List the Corresponding
Setting in Which These
Learning Activities Take
Place
Year(s) of
Training
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#
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#
Updated 4/2015
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List the Learning Activities
Used to Address the Core
Knowledge/Skills
family functioning
[PR VIII.B.2.b)]
Variations in temperament
and adaptive styles; as well
as psychosocial
development
[PR VIII.B.2.c)]
Variations in sexual
development
[PR VIII.B.2.d)]
Developmental and
behavioral aspects of and
adaption to a wide variety of
acute illnesses, chronic
illnesses, physical disabilities
[PR VIII.B.2.e)]
Cognitive disabilities
[PR VIII.B.2.f)]
Language and learning
disorders
[PR VIII.B.2.g)]
Developmental and
behavioral aspects of motor
disabilities, e.g., cerebral
palsy, myelodysplasia,
dystrophies
[PR VIII.B.2.h)]
Autism, Asperger’s
syndrome, autistic spectrum
disorder
[PR VIII.B.2.i)]
Attention disorders
[PR VIII.B.2.j)]
Externalizing conditions,
e.g., aggressive behavior,
conduct disorder,
oppositional defiant disorder
[PR VIII.B.2.k)]
Internalizing disorders, e.g.,
anxiety, mood, and
obsessive disorder, suicidal
behavior
[PR VIII.B.2.l)]
Developmental and
behavioral aspects of
substance use/abuse e.g.,
tobacco, alcohol, illicit drugs
List the Corresponding
Setting in Which These
Learning Activities Take
Place
Year(s) of
Training
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Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 9 of 12
List the Learning Activities
Used to Address the Core
Knowledge/Skills
as a co-morbidity of
developmental and
behavioral disorders
[PR VIII.B.2.m)]
Developmental and
behavioral aspects of child
abuse and neglect (e.g.
physical, sexual factitious) as
it impacts children with
developmental-behavioral
disorders and sequelae of
Child abuse and neglect
[PR VIII.B.2.n)]
Issues arising from variations
in family structure
[PR VIII.B.2.o)]
Somatoform conditions
[PR VIII.B.2.p)]
Sleep disorders
[PR VIII.B.2.q)]
Developmental aspects of
feeding/eating difficulties
associated with
developmental behavioral
disorders
[PR VIII.B.2.r)]
Elimination problems (e.g.,
encopresis, enuresis)
[PR VIII.B.2.s)]
Atypical behaviors (e.g. tic
disorders, self-injurious
behavior, repetitive
behaviors)
[PR VIII.B.2.t)]
Developmental and
behavioral characteristics in
children with genetic
abnormalities
[PR VIII.B.2.u)]
Patient Care - Assessment
Developmental screening
and surveillance techniques
[PR VIII.A.1.a).(1)]
Behavioral screening and
surveillance techniques
[PR VIII.A.1.a).(2)]
Interviewing to ascertain
List the Corresponding
Setting in Which These
Learning Activities Take
Place
Year(s) of
Training
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Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 10 of 12
List the Learning Activities
Used to Address the Core
Knowledge/Skills
family history and family
functioning
[PR VIII.A.1.a).(3)]
Neurodevelopment
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assessment
[PR VIII.A.1.a).(4)]
Assessment of behavioral
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adjustment and
temperament
[PR VIII.A.1.a).(5)]
Understanding of the major Click here to enter text.
diagnostic classification
schemas: DC 0-3; DSMIV,
DSM-PC
[PR VIII.A.1.a).(6)]
Patient Care – Patient Management
Behavioral treatment
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methods
Developmental Interventions Click here to enter text.
[PR VIII.A.2.a)]
Psychopharmacology
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Exposure to therapeutic
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modalities used by other
disciplines
[PR VIII.A.2.a).(1).(a)]
Exposure to early
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intervention, school, and
child welfare systems
[PR VIII.A.2.a).(1).(b)]
Exposure to complementary Click here to enter text.
and alternative therapies
[PR VIII.A.2.a).(1).(c)]
Patient Care – Consultation and Referral
To Primary care providers
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[PR VIII.A.3.a)]
To Pediatric subspecialists
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[PR VIII.A.3.a)]
Early childhood
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daycare/education centers
[PR VIII.A.3.a)]
To schools
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[PR VIII.A.3.a)]
Systems-based Practice
Health care systems
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[PR VIII.C.1.]
Community resources
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Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
List the Corresponding
Setting in Which These
Learning Activities Take
Place
Year(s) of
Training
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Updated 4/2015
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List the Learning Activities
Used to Address the Core
Knowledge/Skills
[PR VIII.C.1.]
Support services
[PR VIII.C.1.]
Structure and administration
of educational programs for
children with and without
special education needs
[PR VIII.C.1.]
Legislative processes
[PR VIII.C.2.]
Health Care Policy
[PR VIII.C.2.]
Child Advocacy
Organizations
[PR VIII.C.2.]
Legal/judicial/child welfare
system
[PR VIII.C.2.]
List the Corresponding
Setting in Which These
Learning Activities Take
Place
Year(s) of
Training
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Outpatient Experiences
1. Will the fellows have patients that they follow longitudinally (long term)? Estimate the average
number of patients that each fellow follows for longitudinal care.
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2. How and by whom they will be supervised during the provision of outpatient care?
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IF THERE ARE ANY UNIQUE SCENARIOS OCCURRING IN THE PROGRAM THAT DO NOT FIT WITHIN THE CONFINES
OF THIS FORM, PLEASE EXPLAIN.
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Developmental Behavioral Pediatrics
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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