Child Health Needs and the Developmental–Behavioral Pediatrics Workforce Supply: 2020–2040

DBP subspecialists care for children with complex conditions by recognizing the multifaceted influences on development and behavior, addressing those problems through interprofessional, systems-based practice, and using a neurodevelopmental, strengths-based approach that optimizes functioning.²  DBP practice focuses on neurodevelopmental and behavioral health conditions; often the intersection of both²  (Table 1).

The prevalence of DB conditions is increasing. Among youth aged 3 to 17 years, the prevalence of neurodevelopmental conditions rose from 12.8% (1997–1999) to 17.8% (2015–2017),³  and recent data indicate that the prevalence of autism spectrum disorder (ASD) has increased from 1 in 150 children (2000) to 1 in 36 (2023).⁶  The prevalence of behavioral and mental health concerns skyrocketed during the coronavirus disease 2019 (COVID-19) pandemic, which may impact children for years to come.⁷  Exposure to additional adverse life experiences, including social and structural drivers of health, especially in the absence of other resiliency factors, further compounds these issues.⁸ 

In the United States, the prevalence of these conditions is unequally distributed among several demographic variables, including geography, race/ethnicity, family income, insurance status, and parental education.^6,9  For example, disparities in service utilization for¹⁰  and identification of racially marginalized children with ASD,¹¹  behavioral health conditions,¹²  and developmental disabilities¹³  have been identified. Caregiver perspectives indicate that the experience of racially marginalized parents differs from their peers in terms of feeling heard and being judged.¹⁴  DBP programs may also lack resources to support families with limited English proficiency. In a survey of 75 academic DBP programs, 31% did not provide language accommodations for families with limited English proficiency.¹⁵  Racial and ethnic backgrounds and other factors further exacerbate gaps in access to and disparities in DBP care.

The field of DBP arose from separate but overlapping efforts to address children’s neurodevelopmental and behavioral needs.²  In 2000, the first DBP subboard of the ABP developed a content outline for the initial certification examination. That content outline also served as a guide for curriculum standardization across existing DBP training programs that had evolved through different funding mechanisms. Over 2 decades later, career options for DBP subspecialists include research, education, advocacy, and clinical practice across diverse patient needs, in a variety of different practice settings, and often in close collaboration with other disciplines.¹⁶ 

On the basis of ABP data through June 2023, 1043 pediatricians have ever been board-certified in DBP, 77% of whom were actively enrolled in Maintenance of Certification (MOC).¹⁷  After the initial exam in 2002, the number of individuals certified per 2-year period decreased substantially, plateauing at ∼50 to 70 per 2-year examination cycle since 2009.¹⁷ 

ABP data on currently certified DBP subspecialists include individuals who may not be in the workforce because of recent retirement, death, or other factors. To correct this, descriptions of the current workforce limit the sample to actively certified pediatricians aged ≤70 years. There were 755 board-certified DBP subspecialists aged ≤70 years in 2023, three-quarters (76.6%) of whom identified as female and one-quarter (23.4%) identified as male (the ABP has only offered options to decline to answer and nonbinary since 2021).¹⁸  The median age was 50 years, one-quarter (23.2%) of whom were aged 61 to 70 years. Regarding details on medical school training, most (73.5%) were American medical graduates (AMGs) with a Doctor of Medicine (MD) degree, whereas 7.9% were AMGs with a Doctor of Osteopathy degree. Another 18.5% were international medical school graduates (IMGs); most had an MD degree (13.4%), and 5.2% had an international degree. Recent race and ethnicity estimates suggest that ∼14.0% of the DBP workforce self-identified as underrepresented in medicine (URiM), with 4.5% self-reporting as Black or African American and 4.6% self-reporting as Hispanic, Latino, or Spanish origin.¹⁹ 

Data on the work characteristics of current DBP subspecialists are collected through the ABP’s MOC enrollment surveys. Note, because of skip patterns in the survey, the percentages reported below are for individual questions. Surveys from 2018 to 2022 (66.7% response rate for DBP) reflect responses from 442 eligible subspecialists aged ≤70 years. Most reported being employed full time (74.9%), with just under half (41.5%) working ≥50 hours per week on average over the last 6 months. Women (29.2%) were more likely to indicate part-time employment status compared with men (8.2%). DBPs had the highest percentage (23.3%) of part-time employment, with most other pediatric subspecialists reporting <10% working part time. Most (26.3%) worked at a medical school/parent university setting or nongovernmental hospital/clinic (14.3%), followed by multispecialty group practice (10.6%) and self-employed solo practice (4.8%). Approximately 53.7% reported that ≥50% of their patients received public insurance.

Specific workforce data for DBP subspecialists in private, community-based practices are limited. In a recent small (n = 22) survey conducted by the Society for Developmental and Behavioral Pediatrics’ Private Practice Committee, most identified their practice type as solo, though several reported that their practice included >1 DBP provider, allied child health providers, and office staff.²⁰  Payer mix was 59% fee-for-service and 41% primarily insurance contracts. To our knowledge, there are no reliable data regarding Medicaid acceptance. Information about active teaching roles associated with an accredited pediatric residency program or medical school is also lacking.

In 2017, a mystery shopper study of DBP programs at US children’s hospitals estimated average wait times of 5.4 months for DBP initial evaluation.¹⁵  Given the significant disruptions to care during the COVID-19 pandemic,²¹  wait times are likely to have increased. Many families of children with DB conditions report unmet health care needs. According to data from the 2016 National Survey of Children’s Health, nearly 30% of children with ASD received neither behavioral intervention nor medication,²²  both evidenced-based interventions for symptoms associated with ASD.

An additional portion of the physician workforce addressing DB needs includes general pediatricians. Although difficult to quantify, MOC survey data indicate that 368 (1.4%) out of the 26 468 general pediatricians reported practicing in DBP.²³  Pediatric and, to some extent, nonpediatric advanced practice practitioners also comprise an important portion of the DBP workforce.²⁴  The professional overlap, differences, and synergies among DBP subspecialists, psychologists, child psychiatrists, and other behavioral mental health professionals have not been well articulated.

When limited to those subspecialists in the United States, the distribution of DBP subspecialists provides insight into these gaps (Fig 1). In 2023, there were an average of 14.1 currently certified DBP subspecialists per state (range 0–104) or 1.0 DBP subspecialists per 100 000 children aged 0 to 17 years (range 0.0–3.8).¹⁷  Three states have no DBPs (Wyoming, New Mexico, and North Dakota). There was wide variability in the distribution of DBP subspecialists within states, with most concentrated in urban settings and few in rural areas. In 2019, the average driving distance to a certified DBP subspecialist was 26.7 miles, ranging from 5.5 miles in Rhode Island to 299.4 miles in North Dakota (excluding Alaska, Hawaii, Puerto Rico, and the District of Columbia).²⁵ 

From academic years 2012 to 2013 to 2021 to 2022, US accredited programs increased from 36 to 44 (+22.2%). However, nearly half of the 30 or more DBP training programs consistently have unfilled slots through the National Resident Matching Program. Some additional slots are offered outside of the National Resident Matching Program Match, leading to recent overall fellowship fill rates of 81.6% (2014) and 75.0% (2022).²⁶  Including individuals who take positions before or after the Match, the number of first-year DBP fellows over the last decade increased from 32 (2012) to a high of 42 (2017), with a steady decrease since 2019 (−12.2% from 2019 to 2022).²⁶  Among current DBP fellows (107) in academic year 2022 to 2023, most (89.7%) identified as female. Regarding medical training, half (48.6%) were AMGs with an MD degree, followed by international medical graduates (IMGs) with an MD degree (27.1%), AMGs with a Doctor of Osteopathy degree (18.7%), IMGs with an international degree (3.7%), and IMGs with an unknown degree (1.9%). The percentage of URiM DBP fellows from URiM backgrounds in 2022 (20.8%) was higher than the DBP subspecialists population (14.0%) in 2023. Figure 1 shows the variability (both in size and geographic location) in DBP fellowship locations in academic year 2021 to 2022. Training location may be significant given that fellows commonly take a first position posttraining near their training location.²⁷ 

Recent publications have highlighted differences in financial remuneration across pediatric subspecialties and in comparison with adult subspecialties. Although reports from 2005 and 2009 suggest compensation may be less important for residents in choosing a pediatric subspecialty career,^28,29  increasing levels of student debt may impact their future decision-making. Among pediatric subspecialists in academic practice, a 2022 publication indicated that DBP subspecialists have the lowest lifetime earning potential (LEP),³⁰  and tend to have less debt than those in other subspecialities, with ∼30.9% of current DBP fellows owing $200 000 or more as compared with 39.5% for all pediatric subspecialty fellows (personal communication, ABP, February 20, 2023). LEP numbers reflect salaries at academic institutions and do not include DBP subspecialists working in hybrid center-based/private community practice or solo private community practice, where LEP could be either higher or lower. LEP also does not take into account employment benefits and other nonsalary remuneration that may further impact financial status.

The workforce model, constructed as a part of this effort, estimates the projected DBP workforce aged ≤70 years from 2020 to 2040 using a microsimulation, data-intensive model that uses historical data to calculate future estimates. The baseline model incorporates the number of subspecialists in the current workforce, and:

1. adds the supply of fellows who complete training and then become certified by the ABP in that subspecialty (held constant at 2019 levels);

2. subtracts pediatric subspecialists who exit the workforce by moving to nonclinical jobs or retiring on the basis of historical probabilities of exit;

3. adds subspecialists who worked outside the United States and then return to provide clinical care; and

4. includes worker diffusion from an initial job to subsequent geographic locations to account for movement of subspecialists around the country.

Projections are provided as headcount (HC, or absolute numbers) per 100 000 children aged 0 to 18 years, and clinical workforce equivalent (CWE), defined as HC adjusted for time spent in clinical and consultative care. Alternative scenarios that modify the model components are also provided at national and subnational levels for census regions and divisions. The model also takes into account changes in the child population at the national and subnational level based on the US Census Bureau³¹ ; differences by subspecialty for census regions are discussed in the summary article in this supplement.³²  Numbers reported below may differ from those in the previous section because of differences in years (2020 vs 2023), sample selection criteria, and inclusion of self-reported clinical time. For more detail on the model, see Fraher et al³³  or the model’s online interactive data visualization tool.³⁴  Estimates of 95% confidence intervals are provided in Tables 2 and 3 and the visualization tool.

The baseline model predicts 69% growth in HC (from 23 289 to 39 253) overall across all pediatric subspecialties combined but to a lesser degree in DBP (45% growth, 663–959) from 2020 to 2040.³⁴  When adjusted for population and population growth over time,³¹  the projected DBP HC increases from 0.8 to 1.0 DBP subspecialists per 100 000 children aged 0 to 18 years by 2040. When further adjusted for CWE, the DBP workforce is projected to grow from 0.5 to 0.6 subspecialists per 100 000 children by 2040. These projections rank DBP as the subspecialty with the fifth smallest projected growth among the 14 ABP-certified subspecialties.

Geographically, the baseline projection predicts growth in all census regions except the Northeast census region, which has the most DBP subspecialists per capita (Fig 2). The South census region is the most underserved in 2020 and will remain so despite the model’s projected 43% increase in growth, which would increase the DBP CWE from 0.35 to 0.5 per 100 000 children by 2040. Estimated DBP HC and CWE per 100 000 children aged 0 to 18 years for the baseline projection and alternate scenarios at the census division levels are presented in Tables 2 and 3, respectively. Within the Northeast census region, the Middle Atlantic (−3%) and New England (−16%) census divisions show decreases in CWE per 100 000 children. In the West census region, the Mountain census division has the lowest DBP presence (0.28 per 100 000 children) and remains low (0.39) despite a +40% change.

When considering alternate scenarios, a 12.5% increase or decrease in fellows by 2030 shifts the baseline projection to 33% and 22%, respectively (±5%). Scenarios that include a 7% increase or decrease in clinical time shift the baseline projection to 37% and 19%, respectively (±9%). The worst-case scenario (12.5% decrease in fellows entering DBP, 7% decrease in clinical time, and increased early exits for all subspecialists) decreases the baseline projection from 28% to 15% growth. The best-case scenario (12.5% increase in fellows by 2030 and 7% increase in clinical time) increases the baseline projection from 28% to 43%.

Certain factors unique to DBP should be considered when interpreting these projections. The model predicts an annual number of trainees entering fellowship on the basis of 2019 data, a year characterized by a higher number of individuals entering DBP fellowship.²⁶  For example, although the ABP 2022 trend data show a 64.0% increase in first-year DBP fellows between 2009 and 2019, there has been a 14.3% decrease in first-year fellows over the last 5 years.³⁵  Thus, it would be reasonable to use the scenario that decreases incoming fellows by 12.5% by 2030 as the baseline projection, which would yield slightly smaller projections when viewed geographically. Notably, a positive supply projection does not necessarily indicate that the field will replenish itself indefinitely and equally geographically. The model’s worst-case scenario (15% increase versus 43% increase in DBP providers) may most appropriately display the direction of the field. It should be noted that the DBP workforce, as measured by HC, will be maintained if the current volume of residents entering DBP fellowship is maintained, with minimal gains.

Historical data involving the DBP workforce and these projected workforce trends together suggest a modest overall growth in HC and CWE over the next 20 years, with significant geographic maldistribution. The high rate of part-time subspecialists (23.2%) and the recent 5-year trend in decreasing numbers of fellows also deserve careful consideration. Below, we present potential solutions to improve child health.

US pediatric residency training has traditionally prioritized monthlong inpatient and intensive care training experiences over primary care and core subspecialty longitudinal rotations in DBP, adolescent medicine, and advocacy. Historical data suggest that this approach has been inadequate to prepare pediatricians to care for children with DB conditions.^36–38  Given the rise in the prevalence of these conditions and the concomitant decrease in conditions cared for in an inpatient setting, the structure of residency training and its related curriculum has not adapted to child health care needs. Not surprisingly, pediatric trainees continue to report low competence in their assessment and treatment of children with developmental disabilities,^39–41  psychosocial problems,⁴²  and behavioral health conditions.⁴³  These competencies are important for residents entering primary care, as well as those entering other pediatric subspecialities. All general pediatricians and subspecialists must learn to recognize and understand how children of all ages and developmental levels respond to illness and health, and appropriately refer children with special health care needs for DBP evaluation.

The length, timing, and nature of resident experiences must change to improve care. The current time-limited, 4-week DBP rotation is inadequate to provide the training needed for future primary care and subspecialty pediatricians. Early, sustained exposure is needed: There is often limited to no exposure to DBP in medical school, and the DBP resident rotation may occur in the second or third year, well past the time trainees entering fellowship decide on their subspecialty.⁴⁴  A longitudinal experience integrated into continuity clinic and other ambulatory and inpatient experiences is recommended to support residents in understanding how DB conditions evolve over time and present in various settings. Targeted mentoring could also have a significant impact; DBP fellows and junior faculty report the need for mentoring that includes career development and research, insights into being a DBP, assistance in navigating academics, and a personal relationship.⁴⁵ 

The sharp contrast between the prevalence of DB conditions and the size of the DBP workforce suggests that innovative models of care are needed. Collaborative models with primary care (eg, colocation of DBP subspecialists in primary care, training general pediatricians to support some aspects of DBP care) have been studied^46–48  and may improve access. Parents and caregivers can also be directed to a primary care medical home⁴⁹  for DB care appropriate for the primary care service sector, especially if increased education and training opportunities can elevate the competence and confidence of primary care practitioners. Clinically relevant waitlist activities can provide population-level care and support to families waiting for a subspecialty evaluation.⁵⁰  The DBP “deserts” in certain regions of the country call for regional centers of excellence,⁵¹  bringing DBP subspecialists and related professions together with primary care, community-based organizations, and schools to better serve patients and families. A general framework for this type of program exists to some extent with the federally funded Leadership Excellence in Neurodevelopmental Disabilities programs, although existing programs may need to be retooled to increase patient access.

The small size of the DBP workforce necessitates efficiency and an understanding of DBP practice by payers and administrators to resource DBP care adequately.⁵²  DBP subspecialists spend significant time in nonface-to-face clinical activities, including report creation, care coordination, and administrative paperwork (eg, previous authorization, form completion).^24,53  DBP revenue streams are substantially lower than procedurally based specialties or those reimbursed on the basis of number of patients seen per day, and staffing to assist with nonface-to-face activities is often limited. In contrast, the strikingly low numbers of DBP subspecialists should necessitate adequate clinical and nonclinical staffing to allow for the unique, high-intensity care they have been trained to do. By nature, DBP practice involves empathy, shared decision-making, and partnerships with children and families regarding conditions without a quick or easy “cure.” Characteristics that make for exceptional DBP subspecialists may also put them at risk for burnout.^54,55  Without adequate administrative support for DBP practice, both the existing workforce and the DBP pathway remain at risk.

Projections from even the best-case scenario indicate that significant advocacy efforts will be needed to meaningfully increase the DBP workforce to meet the needs of current and future children. Economic factors may play a role; pursuing a career in a pediatric subspecialty rather than general pediatrics is a negative financial decision for 12 of 15 specialties.⁵⁶  DBP, however, has the lowest LEP of all pediatric fields.³⁰  DBP competes with pediatric neurology and child and adolescent psychiatry for trainees, both of which have higher LEPs.³⁰  These factors make a strong case for policy changes that provide robust loan repayment and pay equity across pediatric subspecialties. Reducing fellowship time also has been suggested as a possible mitigation strategy. However, reducing fellowship time to 2 years and loan repayment narrow the LEP gap only slightly in economic forecasts; specializing in DBP is still associated with a >$1 million reduction in LEP.³⁰ 

Advocacy is also needed regarding payment for DBP care. Telehealth has provided increased access to DBP care and must be continued beyond the public health emergency declared during the COVID-19 pandemic.⁵⁷  State-by-state medical licensing that creates barriers to care across state lines must also evolve into a national system. Movements toward value-based care may potentially yield improved reimbursement for DBP care,⁵⁸  which may also improve future DBP fellow recruitment. Solutions will take political will to replace the current reimbursement paradigm with an overhaul of current US coding and billing rules that assign higher value to procedurally oriented subspecialties and do not consider the imbalance of supply, patient needs, and market demand. Recent billing changes^59,60  allow DBPs to bill more nonface-to-face time on the day of service, yet DBPs also provide a large amount of nonreimbursable clinical time outside of the day of service²⁴  that is often not captured in traditional billing models. Despite efforts toward value-based care, many health care systems continue to operate in a system that primarily values volume and profit with metrics that are challenging for DBP to meet. Developing, implementing, and providing payment for metrics relevant to DBP care are strongly needed.

Last, the recent impact of the COVID-19 pandemic and the ongoing behavioral health crisis have increased awareness of the importance of behavioral health, yet targeted advocacy is needed to improve recruitment into DBP and access to equitable and timely care nationally. Without clear intent and messaging, DBP as a field and, more importantly, individuals with neurodevelopmental disabilities and coexisting behavioral issues are at risk for being left behind in behavioral health-focused advocacy efforts. Nationally, DBP leaders are invested in improving the visibility of DBP among parents, other professionals, payers, and administrators.² 

The field provides fertile ground for individuals interested in innovation, practice change, advocacy, and meaningful relationships with patients and families. Whereas typical pediatric office visits may last 10 to 15 minutes, DBP clinical visits are longer, allowing for discussion of complex issues and shared decision-making. Lifestyle benefits include limited to no in-hospital calls and opportunities for part-time practice. Graduating DBP fellows are likely to find a large number of job openings, as opposed to other subspecialties, where graduating fellows have lower perceptions of job availability after training.⁶¹ 

No single governing body informs the need for fellowship training across subspecialties regarding the number of programs, slots, and geographic distribution. An analysis of the prevalence of childhood conditions, assessment of the existing workforce, projection of future trends, and plan for adequate training of the US pediatric health care workforce is sorely needed for all pediatric subspecialties, including DBP. More research highlighting the rewards and benefits of DBP practice is needed while continuing to focus on strategies to remedy the significant challenges faced in DBP care, such as qualitative studies involving DBP practitioners and the development of metrics that illustrate cost savings or improved quality of care.

The small numbers of current and future DBP subspecialists in the setting of increasing US rates of pediatric neurodevelopmental and behavioral health conditions represent a crisis in pediatric health care. DBP is a subspecialty with the privilege of caring and advocating for vulnerable children with DB needs, conducting research to understand and address the complexities of disability and behavioral health, and serving as teachers and role models for present and future pediatric professionals. This responsibility has been and continues to be conducted with limited resources, budgetary/financial constraints, and limited time allotted for resident education. Despite their small numbers, DBPs remain core contributors to addressing the “new morbidities” recognized 40 years ago⁶²  that now, more than ever, clamor to be addressed. Recommendations regarding critical changes to training/education, practice, policy, and future research are provided to ensure that the DBP workforce can be well positioned to successfully care for children and families now and in the future.

We thank Emily McCartha, Andrew Knapton, and Adriana R. Gaona for their review of the modeling data presented. We also thank Virginia A. Moyer and Patience Leino for their editorial support. We also thank Marilyn C. Augustyn, Irene M. Loe, Peter G. Smith, and Adiaha Spinks-Franklin for their comments on the manuscript. Last, we thank the pediatricians who shared their information with the ABP Foundation and made this supplement possible.

ABP

American Board of Pediatrics

AMG

American medical graduate

ASD

autism spectrum disorder

COVID-19

coronavirus disease 2019

CWE

clinical workforce equivalent

DB

developmental–behavioral

DBP

developmental–behavioral pediatrics

HC

headcount

IMG

international medical graduate

LEP

lifetime earning potential

MD

Doctor of Medicine

MOC

Maintenance of Certification

URiM

underrepresented in medicine