Child and Adolescent Psychiatry

- This EPA focuses on the application of medical expertise and communication skills to conduct a psychiatric assessment with patients presenting with a mental health concern and their families, using appropriate language, demonstrating sensitivity and establishing rapport. - It includes reviewing preexisting relevant documentation (e.g., referral information, triage) and synthesizing information to develop a formulation, differential diagnosis and initial management plan.

Direct observation by child and adolescent psychiatrist or TTP child and adolescent psychiatry resident Use form 1. Form collects information on: - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Case type: anxiety disorder; attention deficit/hyperactivity disorder; autism spectrum disorder; disruptive behaviour; eating disorder; intellectual disability; mood disorder; obsessive compulsive disorder; other neurodevelopmental disorder; personality disorder; psychotic disorder; somatic symptom disorder; substance use disorder; trauma; other presentation Collect 2 observations of achievement. - At least 1 school age - At least 1 adolescent - At least 2 different case types - At least 1 observation by a child and adolescent psychiatrist

Suggested observations: 2

- This EPA focuses on the performance of a risk assessment of an individual and the implementation of a basic safety plan which includes systemic factors (i.e., family supports/youth protection/applying mental health law to patients at risk of harm to self or others). - This EPA includes assessment of agitation, aggression, threatening behaviour, suicidality and/or self-harm as part of the primary presentation. - This EPA includes completing an environmental safety assessment. - This EPA does not include managing challenging family/system issues that occur in the context of a patient presenting in crisis; that is an EPA of the Core stage.

Direct observation by child and adolescent psychiatrist, general psychiatrist with experience working in emergency and child contexts, or subspecialty child and adolescent psychiatry resident at Core or TTP stage Use form 1. Form collects information on: - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Setting: inpatient; outpatient; emergency; urgent care; consultation liaison; community; indirect consultation - Case type: agitation/aggression/threatening behaviour; suicidality/self-harm - Complexity: low; medium; high Collect 2 observations of achievement. - At least 1 school age - At least 1 adolescent - At least 1 agitation/aggression/threatening behaviour - At least 1 suicidality/self-harm - At least 1 observation by a child and adolescent psychiatrist

Suggested observations: 2

- This EPA focuses on the application of oral communication skills and strategies to convey information, engaging the patients and families in a developmentally informed way for the purpose of shared decision-making.

Direct observation by a child and adolescent psychiatrist or psychiatrist with expertise in Child and Adolescent Psychiatry; this may include feedback from the patient/family Use form 1. Form collects information on: - Interlocutor(s) (select all that apply): patient; family; none Collect 3 observations of achievement. - At least 1 observation of communication with a patient - At least 1 observation of communication with a family - At least 2 different observers

Suggested observations: 3

- This EPA focuses on conducting clinical interviews with a patient and one or more family members, and presenting the findings of the family assessment to the supervisor. - This includes observing and describing salient factors in family functioning such as: hierarchy; nonverbal cues; attachment style; parenting style; parent-child temperament mismatch/fit; cultural factors (e.g., immigration); different constellations (e.g., single parent, divorce, blended); co-parenting relationship; intergenerational factors (e.g., trauma); instrumental functioning (e.g., groceries, daily routines). - The observation of this EPA is divided into two parts: direct observation of the interview, and case discussion with oral reflection.

Part A: Direct observation Direct observation by child and adolescent psychiatrist or other health professional with expertise in family therapy (e.g., social worker, psychologist) Use form 1. Form collects information on: - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Complexity: low; medium; high Collect 3 observations of achievement. - At least 1 school age - At least 1 adolescent - At least 2 different observers - At least 1 child and adolescent psychiatrist observer Part B: Case discussion with oral reflection Case discussion, including trainee reflection, with child and adolescent psychiatrist or other health professional with expertise in family therapy (e.g., social worker, psychologist) Use form 1. Form collects information on: - Interview observed: yes; no - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Complexity: low; medium; high Collect 3 observation of achievement. - At least 1 case discussion must be for an interview that was directly observed - At least 1 school age - At least 1 adolescent - At least 2 different observers - At least 1 child and adolescent psychiatrist observer

Suggested observations: 3

- This EPA focuses on documentation for the medical record and for communication with hospital and community-based health care providers and other relevant community professionals (e.g., school staff). - The documentation should include a developmental formulation with relevant details that inform diagnosis, prognosis, and treatment plan. - The report should be appropriate to the role of the recipient and in accordance with the needs of the patient and family, meeting appropriate privacy legislation.

Review of documentation of the comprehensive psychiatric assessment by child and adolescent psychiatrist, with feedback from document recipients if possible. Use form 1. Form collects information on: - Interview directly observed: yes; no - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Case type: anxiety disorder; attention deficit/hyperactivity disorder; autism spectrum disorder; disruptive behaviour; eating disorder; intellectual disability; mood disorder; obsessive compulsive disorder; other neurodevelopmental disorder; personality disorder; psychotic disorder; somatic symptom disorder; substance use disorder; trauma; other presentation (please specify) - Setting: inpatient; outpatient; emergency; consultation liaison; community; residential treatment centre - Complexity: low; medium; high - Intended recipient (write in): Collect 4 observations of achievement. - At least 1 document review for an interview that was directly observed - At least 2 different age groups - At least 2 different case types - At least 2 different settings - At least 4 medium or high complexity - At least 2 different observers

Suggested observations: 4

- This EPA focuses on the performance and interpretation of physical examination procedures relevant to the diagnosis, differential diagnosis, and treatment plan. - It includes conducting examinations relevant to medication trials, such as examinations for metabolic syndrome and extrapyramidal side effects.

Direct observation by child and adolescent psychiatrist, other physician (hospitalist, pediatrician, pediatric subspecialists, family physician), nurse practitioner, Core or TTP pediatric/pediatric subspecialty resident, or TTP child and adolescent psychiatry resident Use form 1. Form collects information on: - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Case mix (select all that apply): catatonia; tics; movement disorder; dystonia; akathisia; Parkinsonian symptoms (EPS); tardive dyskinesia (TD); first episode psychosis; medication side effect; medication monitoring; somatic symptom and related disorders; eating disorder; genetic syndromes; other presentation (please specify) Collect 4 observations of achievement. - At least 1 school age - At least 1 adolescent - At least 1 assessment for EPS - At least 1 assessment for medication monitoring or side-effects - At least 2 observations by supervising staff physician (i.e., not a trainee)

Suggested observations: 4

- This EPA focuses on respectful and effective collaboration with the care team. - This includes an understanding of and valuing the various roles and scope of practice of interprofessional team members. - This EPA may be observed within various settings, such as in the emergency department, inpatient unit, clinic or community setting and in case conferences, team meetings, or family meetings. - The observation of this EPA is based on at least one month of clinical experience.

Direct and indirect observation by supervising child and adolescent psychiatrist, with feedback from members of the interprofessional team Use form 3. Form collects information on: - Input collected from (select all that apply): case worker; counsellor; nurse; occupational therapist; psychologist; social worker; speech language pathologist; teacher; other team member - Setting: inpatient; outpatient; emergency; consultation liaison; community Collect 1 observation of achievement - At least 2 members of team providing input

Suggested observations: 1

- This EPA focuses on synthesizing patient information to develop a formulation and write a report for patients with a complex presentation. - Examples of complexity include: medical (e.g., medical illness, concurrent disorders/substances, intellectual disability, multiple psychiatric diagnoses, treatment refractory, multiple care providers), linguistic (e.g., barriers to communication), and psychosocial (e.g., family discord, parental psychopathology, low socioeconomic status, acculturation). - This EPA should be observed across the spectrum of age and development, and with various categories of complexity (e.g., medical, linguistic, psychosocial). - This EPA may be observed in a simulation setting.

Direct observation, case discussion, and/or review of documentation by child and adolescent psychiatrist Use form 1. Form collects information on: - Observation type (select all that apply): direct; case discussion; review of documentation - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Setting: inpatient; outpatient; consultation liaison; community; residential treatment centre; simulation - Case type (select all that apply): anxiety disorder; attention deficit/hyperactivity disorder; autism spectrum disorder; disruptive behaviour; eating disorder; intellectual disability; mood disorder; obsessive compulsive disorder; other neurodevelopmental disorder; personality disorder; psychotic disorder; somatic symptom disorder; substance use disorder; trauma; other presentation - Abuse/trauma/neglect component: yes; no - Level of complexity: low; moderate; high Collect 5 observations of achievement. - At least 1 of each age group - At least 2 in outpatient setting - A variety of case type - At least 1 intellectual disability or autism spectrum disorder - At least 1 eating disorder - At least 1 trauma/abuse/neglect component - All cases must be of moderate or high complexity - At least 2 different observers

Suggested observations: 5

- This EPA focuses on the application of oral communication skills to share formulations and treatment plans with patients and families who have complex presentations and engage them in their care. - It also includes identifying and addressing barriers to following the treatment plan, and obtaining informed consent for therapies.

Direct observation by child and adolescent psychiatrist, which may include input from patients and/or families Use form 1. Form collects information on: - Age: infant/preschool (under 6); school age (6-12 ); adolescent (over 12) - Case type (select all that apply): anxiety disorder; attention deficit/hyperactivity disorder; autism spectrum disorder; disruptive behaviour; eating disorder; intellectual disability; mood disorder; obsessive compulsive disorder; other neurodevelopmental disorder; personality disorder; psychotic disorder; somatic symptom disorder; substance use disorder; trauma; other presentation - Abuse/neglect/trauma component: yes; no - Setting: inpatient; outpatient; emergency; consultation liaison; community; residential treatment centre - Complexity: low; medium; high Collect 6 observations of achievement. - At least 1 of each age group - At least 3 different primary diagnosis - At least 1 intellectual disability or autism spectrum disorder comorbidity - At least 1 abuse/neglect/trauma component - At least 2 different settings - At least 3 high complexity - At least 3 different observers

Suggested observations: 6

- This EPA focuses on the use of the skills that underpin most psychotherapeutic modalities, namely formation of a therapeutic alliance, empathy, and cultural adaptations, as applied to family therapy, structured behavioural interventions for children with disruptive disorders (e.g., Incredible Years, SNAP, Triple P) and at least one other evidence-based treatment, such as cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT) or interpersonal psychotherapy (IPT). - It includes educating the patient and/or family on the rationale and specific therapeutic components of the prescribed psychotherapeutic intervention (e.g., CBT cognitive model of depression, avoidance model of anxiety). - This EPA includes individual, family, or group settings. - The observation of this EPA must include some cases for which input from the patient/family (e.g., using the Working Alliance Inventory) is integrated into the assessment by the supervisor.

Part A: Performing psychotherapy Direct observation or review of audio, video or discussion of process notes with supervisor (e.g., psychiatrist, clinical psychologist, clinical social worker, psychoeducator, occupational therapist, mental health nurse), with input from patients and/or families when possible Use form 1. Form collects information on: - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Case type: anxiety disorder; eating disorder; mood disorder; obsessive compulsive disorder; personality disorder; psychotic disorder; substance use disorder; trauma; other disorder - Focus of observation (select all that apply): alliance; empathy; psychoeducation; cultural adaptations - Therapeutic modality: family therapy; CBT; DBT; IPT; behavioural intervention for disruptive behaviour; other - Treatment (select all that apply): integrated; longitudinal - Feedback from patient: yes; no Collect at least 6 observations of achievement. - At least 2 different age groups - At least 3 alliance - At least 3 empathy - At least 3 psychoeducation - At least 1 cultural adaptations - At least 1 family therapy - At least 1 behavioural intervention for disruptive behaviour - At least 1 other psychotherapy modality - At least 3 observations demonstrating integration of psychotherapeutic interventions in regular clinical care - At least 2 observations incorporating feedback from patient - At least 2 supervisors Part B: Logbook Submit logbook of psychotherapy sessions and any other assessments (specific to the assessment of psychotherapy) required by program to Competence Committee Logbooks tracks: - Modality (write-in): - Treatment (write-in):

- This EPA includes initiating, monitoring and managing pharmacologic treatments, including assessing response to therapy, adverse effects, and adherence to therapy as well as discontinuing and/or deprescribing therapy, as appropriate. - This EPA includes the use of off-label and non-first line treatments. - This EPA may be observed in a simulation (e.g., OSCE) setting.

Direct observation, documentation review and/or case discussion by supervisor Use form 1. Form collects information on: - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Class of medication (select all that apply): stimulant; non-stimulant ADHD medication; antidepressant; antipsychotic; lithium; anticonvulsant; sedative/hypnotic; other medication - Medication(s) (write in): - Activity (select all that apply): starting medication; medication management (including monitoring, dose-adjustment, switching, augmenting); discontinuing/ deprescribing - Setting: clinical; simulation Collect 20 observations of achievement. - At least 1 infant/preschool - At least 3 school age - At least 3 adolescent - At least 2 starting stimulant (including 1 methylphenidate and 1 amphetamine) - At least 1 starting non-stimulant ADHD medication - At least 2 starting antidepressants - At least 2 starting antipsychotics - At least 1 starting or managing lithium - At least 1 starting or managing anticonvulsant - At least 1 starting or managing clozapine - At least 2 managing stimulant - At least 1 managing non-stimulant ADHD medication - At least 2 managing antidepressants - At least 2 managing antipsychotics - At least 2 patients on multiple psychiatric medications - At least 2 deprescribing medication - No more than 3 in simulation setting - At least 3 different observers

Suggested observations: 20

- This EPA focuses on demonstrating a leadership role with interprofessional colleagues in providing care in a variety of settings (e.g., school, primary care, forensic). - This EPA also includes advocating effectively within the team for the needs of the patient, and engaging available resources to support the patient and family. - This EPA includes identifying and addressing team dynamics. - The observation of this EPA is based on a period of time of at least a month. - This EPA is observed in two parts: observation by the supervisor, and trainee reflection of team dynamics. - The observation of the reflection on team dynamics is based on the supervisor’s review of an oral reflection that provides a formulation of team dynamics and how it influenced their interventions.

Part A: Leadership in interprofessional care Direct observation by supervising child and adolescent psychiatrist, with input provided by interprofessional team members Use form 3. Form collects information on: - Setting: inpatient; outpatient; consultation liaison; community - Input provided by: case worker; child welfare worker; counsellor; justice professional; nurse; occupational therapist; psychologist; school professional; social worker; speech language pathologist; other team member Collect 2 observations of achievement. - At least 2 different settings Part B: Trainee reflection Review of trainee oral reflection by supervisor Use form 4. Collect 1 observation of achievement.

Suggested observations: 2

- This EPA focuses not only on accurate assessment of level of risk, but also decision- making regarding a management plan, as well as disposition and knowledge of the legal requirements and available resources/setting. - It includes the integration of information from multiple sources, including risk assessment of the patient, family dynamics, and systemic issues. - Management may involve non-pharmacological or pharmacological interventions to manage an agitated patient, and interventions to manage challenging family and system dynamics. - This EPA may be observed in a variety of settings, including emergency/urgent care, inpatient and outpatient settings, and telepsychiatry.

Direct observation or case discussion by child and adolescent psychiatrist or TTP child and adolescent psychiatry resident Use form 1. Form collects information on: - Observation type: direct; case discussion - Age: infant/preschool (under 6); school age (6-12); adolescent (over 12) - Setting: inpatient; outpatient; emergency; urgent care; consultation liaison; community; indirect consultation - Management component (select all that apply): agitated patient-non- pharmacological; agitated patient-pharmacological; complex family; systems-related challenge - Complexity: low; medium; high Collect 6 observations of achievement. - At least 4 direct observation - At least 2 infant/preschool or school age - At least 2 adolescents - At least 1 in emergency or urgent care setting - At least 1 of each management component - All at least medium or high complexity - At least 5 high complexity - At least 2 different child and adolescent psychiatrist observers

Suggested observations: 6

- This EPA includes posing a clinically relevant question, performing a literature search and critically appraising the literature. - This may be related to any aspect of child and adolescent practice, including basic or clinical science, quality improvement, or medical education. - This EPA may be observed in a grand rounds or comparable academic setting involving a review of multiple sources from the literature. Residents may also demonstrate the achievement of this EPA via submission of a manuscript suitable for publication to a peer reviewed journal, or presentation of the project at a peer- reviewed local, regional, provincial or national scientific meeting.

Direct observation by supervisor Use form 1. Collect 1 observation of achievement.

Suggested observations: 1

- This EPA focuses on providing appropriate and timely advice about clinical management without direct contact with the patient, neither in person nor through telehealth. - It includes recognizing concerns that can be managed indirectly versus those that require direct assessment. - Observation of this EPA must include review of the resident’s documentation of the encounter.

Direct observation or case discussion, with review of documentation, by supervisor; this may include input from interprofessional or physician colleagues involved in the interaction. Use form 1. Form collects information on: - Types of observation (select all that apply): direct; document review; case discussion; colleague input - Input provided by (write in): Collect 2 observations of achievement. - At least 1 with either direct observation or input from interprofessional or physician colleague involved in the interaction

Suggested observations: 2

- This EPA focuses on the child and adolescent psychiatrist’s role in overall delivery of patient care. - This includes evidence-informed decision-making across the breadth of presentations and case complexity, and running the service or practice efficiently and in a manner consistent with sustainable practice and work-life balance. - This includes triaging patient referrals, prioritizing competing interests, demonstrating time management, documenting challenging situations, providing indirect consultation, and using resources responsibly. - It also includes managing adverse events both clinically and administratively, and leadership through self-reflection and analysis of team dynamics. - It also includes the administrative aspects of practice such as patient advocacy, and financial management, and the other responsibilities of an attending physician such as supporting the interprofessional team and maintaining a professional work environment. - The observation of this EPA is divided into two parts: patient care; working with the team. - The patient care aspects of this EPA are based on at least one month of observation.

Part A: Patient care Direct observation by supervising psychiatrist Use form 1. Form collects information on: - Setting: inpatient; outpatient; emergency; consultation liaison; community Collect 1 observation of achievement. Part B: Working with the team Collation of feedback from multiple observers by supervisor; observers may include other physicians, social workers, nurses, OT/PT, administrators, peers, junior residents, or subspecialty residents Use form 3. Form collects information on: - Number of people providing input (write in): Collect 2 observations of achievement, at least one month apart. - Each observation must include feedback from at least 2 observers

Suggested observations: 1

- This EPA focuses on providing appropriate supervision and opportunities for autonomy: triaging the level of supervision according to acuity, setting, and trainee and patient needs; delegating appropriately; and being available in case of emergency. - This EPA also includes coaching junior trainees, assessing the performance of others, and providing feedback.

Direct observation by supervisor, with input from other health care professionals and learners Use form 1. Form collects information on: - Setting: inpatient; outpatient; emergency; consultation liaison; community; on-call Collect 4 observations of achievement.

Suggested observations: 4

- This EPA focuses on recognizing gaps in performance, personal career goals, and/or needs of the intended practice setting, and developing and implementing a personalized training experience to address them. - This may include developing further expertise in an area of interest such as a clinical focus, research, education scholarship, health advocacy, or administration. - Achievement of this EPA includes a) providing a learning plan with rationale, personal needs assessment, and identification of the methods and activities necessary for its achievement; b) submission of evidence of achievement in each area/setting identified in the learning plan – the outcomes must be SMART (specific, measurable, achievable, relevant, timely); and c) reflection on the effectiveness of the plan’s design for the trainee’s development, highlighting strengths and areas for improvement and reflecting on how future learning plans can be improved. - The observation of this EPA is divided into three parts: developing a learning plan; implementing a training experience; reflecting on learning.

Part A: Developing a learning plan Review of resident’s submission of a reflective learning plan identifying activities to achieve by supervisor Use form 4. Collect 1 observation of achievement. Part B: Implementing a training experience Direct observation by supervisor Use form 1. Collect 1 observation of achievement. Part C: Reflecting on learning plan efficacy Review of resident’s submission by supervisor Use form 4. Collect 1 observation of achievement.

Suggested observations: 1