Defining Developmental-Behavioral Pediatrics

Leaders in the DBP field who hold prominent leadership roles nationally in some of the major pediatric organizations, as well as at their academic institutions, were identified by the current president of the Society for Developmental and Behavioral Pediatrics (SDBP) to develop the definition of DBP and this article. Existing definitions of DBP (eg, from SDBP and the Council of Pediatric Subspecialties) were reviewed along with the entrustable professional activities (EPAs) developed by the American Board of Pediatrics (ABP) to delineate professional competencies. Based on these existing definitions and the consensus of this expert group, a working definition was developed. A draft manuscript including the definition was developed and reviewed by the SDBP Board of Directors. The definition and subsequent manuscript were submitted for review and comment to the entire membership of SDBP. Following incorporation of these comments, the SDBP Board of Directors again had the opportunity to offer comment and endorsed the manuscript. Therefore, this article, including the definition of the field, represents the input and views of thought leaders, current subspecialty leadership, and professionals within the field of DBP.

The field of DBP evolved out of a confluence of societal factors, including advances in medical sciences and changes in societal perspectives of child development.^5,6  As pediatric medical science advanced with the advent of antibiotics, vaccinations, and improvements in neonatal care after World War II, the importance of addressing the social and emotional needs of families in which children were reared received greater attention by pediatricians, child psychologists, and child psychiatrists. Pediatricians shifted their practice from treating acute pediatric diseases to incorporating the management of chronic diseases, disabilities, and behavioral and emotional concerns.

In 1948, the American Academy of Pediatrics established the Section on Mental Growth and Development to address the psychosocial needs of children. This section had difficulty finding a focus and was disbanded in 1958. In 1960, the American Academy of Pediatrics established the Section on Child Development, which later became the Section of Developmental and Behavioral Pediatrics in 1988. In the 1950s, the first iteration of a DBP fellowship was founded at Yale School of Medicine and the State University of New York Upstate Medical Center in Syracuse. By the 1960s, several pediatric and child psychiatry departments around the country began to collaborate on addressing the psychosocial needs of children and families. Subsequently, the William T. Grant Foundation funded fellowships in “Psychological Pediatrics” at The Johns Hopkins University School of Medicine and the Children’s Hospital of Philadelphia.

Concurrently, the developmental needs of children were also receiving greater national attention. In 1962, President Kennedy established the President’s Panel on Mental Retardation that evolved into the University Affiliated Facilities. Over time, the University Affiliated Facilities ultimately became the University Centers for Excellence in Developmental Disabilities. Throughout the 1960s, the Kennedy Foundation and the Public Health Service Mental Retardation Branch provided grants to universities around the country to establish programs to provide multidisciplinary training of specialists, including pediatricians, to work with children having handicapping conditions. These programs came to be known as Leadership Education in Neurodevelopmental and Related Disabilities programs. In 1964, the University of Rochester School of Medicine established a fellowship in “Adolescent Medicine, Behavior, and Community Health.” Three years later, Dr Julius Richmond, who would go on to become surgeon general during the Carter Administration, declared that “child development is the basic science of pediatrics.”⁷  During the 1960s, the field of neurodevelopmental disabilities also began to emerge, focused on the evaluation and care of children with developmental disabilities, including disorders of language, movement, the special senses, and cognition.

In the 1970s, Dr Robert Haggerty coined the phrase the “new morbidity”⁸  and termed this blossoming field of pediatrics “behavioral pediatrics,” which was initially viewed as a component of general pediatrics rather than as a separate subspeciality. Throughout the 1970s, training programs in behavioral pediatrics emerged across the country, with funding from the Maternal and Child Health Bureau and the William T. Grant Foundation. In parallel, by 1978, the Society for Developmental Pediatrics (SDP) was established as a professional home for pediatricians interested in the field of neurodevelopmental disabilities. In 1980, the Journal of Developmental & Behavioral Pediatrics (JDBP) was established to provide a research publication home for professionals in the fields of neurodevelopmental disabilities and behavioral pediatrics.

In 1982, the Society for Behavioral Pediatrics (SBP) was established as an interdisciplinary professional home for behavioral pediatricians, child psychologists, and other professionals caring for children with behavioral disorders and held its first annual meeting in 1983. In 1994, the SBP became the Society for Developmental and Behavioral Pediatrics (SDBP) and JDBP became the official journal for the society.

In the 1990s, members of the SBP and SDP sought to become a board-certified subspecialty of pediatrics. After much debate, the two societies sought separate paths for board certification: the SBP petitioned the ABP to become an official pediatric subspecialty, and the SDP petitioned both the ABP and the American Board of Psychiatry and Neurology to jointly sponsor certification in the field of neurodevelopmental disabilities. In 1999, the American Board of Medical Specialties approved board certification of both petitions. DBP became a fellowship training program, and neurodevelopmental disabilities became a residency training program within neurology with the option for triple board certification.⁹ 

In 2000, the ABP established a subboard of DBP. Fellowship programs in DBP were accredited by the Accreditation Council for Graduate Medical Education (ACGME) for the first time in 2002 and the ABP offered the first board certification examination in DBP. While the field of DBP only became an ABP-certified subspecialty approximately 20 years ago, the origins of DBP began long before the certification process was finalized.

The history of DBP training parallels the interwoven strands of developmental disabilities and behavioral needs in the history of the field itself. Components of early fellowship training were often focused on the interests and skill sets of individuals who self-defined as DBPs at specific institutions. The approval of a specific sub-board in DBP facilitated standardization of fellowship training through ACGME training requirements and informed ABP credentialing procedures. Current training and future trends are described below.

To become an ABP-certified DBP physician, one must complete medical school at an accredited allopathic or osteopathic program (or the international equivalent), 3 years of medical residency in pediatrics in an accredited program, pass the ABP certification exam in general pediatrics, complete 3 years of fellowship training in DBP, and pass the ABP DBP subspecialty certification examination. They cannot sit for their ABP subspecialty certification examination unless their program director certifies that they are competent to practice. Thus, DBPs are extremely well-trained medical subspecialists with competencies in medical prevention, diagnosis, and treatment as well as developmental-behavioral norms and variations and their management.

Because multiple intricate and interacting genetic or epigenetic, medical, environmental, cultural, socioeconomic, and educational factors affect child development and behavior, as well as the frequency with which developmental-behavioral problems co-occur with other conditions, DBP fellows are required to complete rigorous interprofessional training. DBP fellows are trained to assimilate knowledge and technical skills acquired through training in diverse medical, allied health, and community settings. DBP fellows often are trained and mentored by professionals from many medical and mental health subspecialties (eg, child and adolescent psychiatrists, developmental and clinical psychologists, child neurologists, medical geneticists, pediatric physical medicine and rehabilitation clinicians, and adolescent medicine clinicians) and allied health fields (eg, behavior analysts, audiologists, speech and language pathologists, occupational therapists, physical therapists, and social workers). This results in a comprehensive systems-based approach to care for children with complex developmental-behavioral conditions.¹⁰ 

DBP fellows participate in individual and interdisciplinary team evaluations and often receive training directly in the community, including at early intervention programs, public and specialized schools, applied behavior analysis therapy programs, medical-legal partnership organizations, and/or residential treatment centers. Given the breadth and complexity of DBP training, by the time DBP fellows are ready to practice independently, they are trained to integrate the findings from medical, therapeutic, educational, and community evaluations to make comprehensive developmental-behavioral diagnoses and direct care. The interdisciplinary nature of DBP training also ensures that DBP physicians are extensively and directly trained to effectively communicate DBP diagnoses and recommendations for intervention and treatment to families and representatives from schools and community organizations. They can promote a shared understanding of each child’s pattern of developmental-behavioral strengths and challenges and foster cross-disciplinary engagement in clinical decision making and treatment.

Interventions for children with DBP conditions require an extensive combination of medical and therapeutic treatments and educational services. Unproven, and potentially harmful, nonstandard pharmaceuticals and therapies are commonplace and may confuse parents looking for answers for disorders where clear etiology and “cure” are unknown. Thus, DBP fellows receive focused training in evidence-based interventions to develop the expertise to recommend appropriate medical, therapeutic, educational, and behavioral supports for their patients. Research training and scholarships also build the opportunity for continual lifelong learning and discovery of the etiology of complex disorders, testing, and implementation of new, effective diagnostic tools and treatments.

Unlike most other medical subspecialties, the bulk of interventions for children with developmental-behavioral disorders must be obtained in the community (eg, early intervention or special education services, private therapeutic interventions, acute behavioral crisis interventions), rather than in the medical office or inpatient setting. The extensive community training undertaken by DBP fellows enables DBPs to provide systems-based and coordinated care and ensures that they can effectively advocate for programs and policies that positively impact children with developmental-behavioral disorders and their families on local, regional, state, and national levels.¹⁰ 

In the past decade, the ABP, in conjunction with the pediatric community, has developed EPAs to delineate the professional competencies for the 15 ABP subspecialties with the goal that trainees demonstrate they can perform these EPAs without supervision in preparation for future independent practice.¹¹  EPAs are currently voluntary; fellows in DBP training programs are ranked independently on 5 DBP-specific EPAs, in addition to the 7 EPAs required of all pediatric medical subspecialists. The 5 DBP-specific EPAs are designed to define the professional work of all DBPs and characterize the approach of DBP, distinguishing it from other medical subspecialties (Table 1). To further distinguish the specific medical subspecialty of DBP, the ABP DBP-specific EPAs identify problems that should be managed by a DBP physician from those that should be managed by primary care physicians and those that generally require referral, consultation, or interprofessional management provided by other medical subspecialists and/or allied health professionals.¹⁰  These EPAs align closely with the components of DBP training outlined above and have informed the definition of the field outlined in this manuscript. The ABP is moving toward requiring a core set of EPAs before being credentialed for pediatric residents; it is anticipated the ABP will also require these for pediatric subspecialties.

While subspecialty distinction could have led to a unified definition of DBP practice, it has remained difficult to define. The following factors contribute to challenges regarding the definition of and variability within the field.

Current data about DBP practice frames this discussion. ABP data indicate that only 904 pediatricians have been board-certified in DBP since its inception in 2000; 706 physicians were maintaining active certification in DBP in March 2020.¹²  In 2019, there were a total of 120 DBP fellows across all 3 years of fellowship training in the United States. In 2021, despite this being the highest number of applicants ever to the National Resident Matching Program Pediatric Subspecialties match and a 7.0% increase above 2020, there were only 26 applicants matched to DBP fellowships and more than 50% of available first-year fellowship positions were unfilled. Compare this with fields such as neonatal-perinatal medicine that had more than 10 times the number of matched fellow applicants (275, 97.2% of positions filled) and an overall match rate across all subspecialties of 86.9%.¹³ 

For a relatively small field within pediatrics, DBPs engage in a variety of practice settings ranging from solo to hospital-based practice. Data from 194 DBPs reenrolling in ABP Maintenance of Certification from 2019 to 2020 suggest that approximately two-thirds are hospital-based, and the remaining one-third are in solo to multispecialty practice or are working in health maintenance organizations. Fifteen percent of DBPs report being self-employed. Academic engagement is common: 78% have a faculty appointment, 73% are involved in education, and 37% are involved in research. Approximately half (51%) report that 75% or more of their time is spent in clinical care.¹² 

Conditions cared for by DBPs also vary substantially. Across 12 academic DBP sites (n = 50 physicians) surveyed from 2013 to 2014, DBPs were working in 29 different clinic settings, ranging from clinics that evaluate for specific diagnoses (most commonly, autism spectrum disorder [ASD] and attention-deficit/hyperactivity disorder [ADHD]), but also clinics dedicated to care of children with specific genetic syndromes (eg, Down syndrome), chronic conditions (eg, cerebral palsy), and medically complex conditions (eg, prematurity, congenital cardiac disease).¹⁴ 

Reasons for DBP referral are multiple and often cooccurring. Data published in 2018 examining almost 800 referrals to DBP clinics found referred children to have an average of 3 DBP concerns,¹⁵  highlighting the clinical complexity of children referred for DBP evaluation and care. Some of the reasons children may be referred to a DBP are included in Table 2.The paucity of DBPs coupled with a broad scope of clinical practice across a variety of different clinical settings contributes to the ensuing difficulties in succinctly defining DBP practice.

DBPs in larger organizations, hospitals, and academic medical centers rarely hold positions wherein decisions about finances and practice environments are made, and those in leadership roles often do not understand the unique aspects of DBP practice, in part due to the lack of understanding of the field. Prior authorization requirements differ significantly across local settings, as well as requirements for specific types of evaluations that need to be completed to qualify for services, which can mandate or limit the disciplines that can be involved in a DBP evaluation.

There is not a predictable structure for where DBPs fall within larger systems. For example, in an academic medical center, DBP may be an independent division or may fall within the divisions of general pediatrics or other pediatric subspecialities (eg, neurology, or behavioral or mental health), all with very differing names and identifiers. These different organizational structures can have significant implications for resource allocation and DBP visibility. For example, if measured against general pediatrics for visit throughput or procedural specialties for relative value unit (RVU) generation, DBP physicians often will fall short due to longer visit times and poor reimbursement. Like DBP, behavioral health professionals tend to have longer visit times, but, unlike DBP, the care provided in behavioral health may not come with as much cost for additional support, such as nursing staff.

DBP practice often has evolved based upon the organizational or community landscape in which it is practiced, leading to wide variations. For example, within some academic centers other disciplines that care for children with DBP or mental health problems are represented while at others, there is a paucity of other clinicians available to manage children presenting with these problems. Are psychologists available to conduct psychoeducational testing in-house, or do DBPs do that testing themselves, or refer out to other community resources? How robust are the community early intervention system and school system services when children are identified as at-risk? Is there a local behavioral health system, and, if so, are there restrictions on the types of children seen by age, developmental status (eg, physical or cognitive disabilities), insurance accepted, geography or sector involvement (eg, foster care)? In many communities, DBP practice is shaped by answers to questions like these to fill gaps in care localized to that community, academic medical center, or catchment area.

Although there is often overlap in the scope of care, DBPs are distinct from general pediatricians and other subspecialists.

While a small minority of DBPs also provide primary care, the vast majority function in the subspecialist role of caring for children with developmental and behavioral problems. Due to long wait lists, DBPs’ role may be restricted to establishing a diagnosis and plan for intervention; at other centers, it may involve providing longitudinal, coordinated care. DBPs can determine a developmental-behavioral diagnosis (Table 2); direct the etiological evaluation; provide counseling to children and families; prescribe psychotropic medications to address behavior, emotional and regulatory problems; and offer recommendations for intervention in children with neurodevelopmental disorders including ASD, intellectual disability, and language and learning disabilities.

It would be an impossible task for DBPs or other subspecialists to care for all children with DBP problems, given the high prevalence^1,2  and the limited numbers of board-certified DBPs practicing nationally. DBPs, therefore, are needed when children have problems of greater severity or complexity, such as multiple co-occurring problems and disorders¹⁶ ; general pediatricians need to be able to care for the majority of children with mild or moderate developmental-behavioral concerns. DBPs have designed many of the educational initiatives and written key policies and guidelines that have helped primary care providers gain a greater understanding of the variations within typical childhood behavior and development, along with key contextual factors, such as the presence of supportive relationships and family functioning. All pediatric residents are mandated by the ACGME to complete a rotation in DBP to learn about the broad presentation of developmental-behavioral problems across childhood. These educational initiatives have trained primary care providers to be able to deliver DBP care in general pediatric settings, but there remains a need for greater training of general pediatricians in residency and throughout practice, so they can increase their comfort level and competence in managing mild to moderate DBP problems, such as uncomplicated ADHD.

In schools and childcare settings, DBPs lead and collaborate in efforts to promote early detection and treatment of behavioral and emotional problems and developmental variations. As a field, DBP has led in cross-disciplinary national partnerships for prevention, screening, surveillance, and management within these settings. Importantly, DBPs have had a significant leadership role in designing and implementing pediatric primary care and other population-level efforts to reduce disparities in early child development and school readiness (eg, Reach Out and Read), which result from poverty and structural racism, and place children at risk for adverse educational, health, and mental health outcomes across the lifespan. Consideration of the impact of social determinants of health and structural racism on childhood development and behavior is a core part of DBP training.

Thus, the DBP physician serves as a subspecialty consultant for children with developmental and behavioral problems with a high level of complexity requiring close integration of medical and community-based services.

There are 10 times as many child and adolescent psychiatrists (CAPs) than DBP’s practicing nationally.¹⁷  While there is significant overlap between the two fields, in that both DBPs and CAPs treat children with developmental-behavioral disorders and partner with allied professionals, there are also significant differences. CAPs often bring expertise to the diagnosis and management of severe mental health disorders, such as psychosis, suicidality and severe depression or anxiety, bipolar disorder, substance use, and conduct problems, particularly in children without underlying neurodevelopmental problems.

While DBPs complete thorough neurologic assessments, DBPs frequently collaborate with neurologists regarding children with specific neurologic findings or disorders, such as epilepsy or headache. Correspondingly, neurologists may conversely refer children who require more community wraparound support, such as children with learning disabilities, behavioral variations, ADHD, and ASD to DBPs. Neurodevelopmental disabilities specialists may work within neurology departments and/or DBP departments, depending on the academic center or practice location, and often bring expertise regarding neurodevelopmental disorders.

Finally, the practice of DBP differs from that of child psychologists. DBP fellowships include training in diagnostic neurodevelopmental assessment, including administration and interpretation of standardized tests of development and behavior, and in the implementation of evidence-based behavioral interventions. DBPs frequently refer children, however, to child psychologists when more comprehensive psychoeducational or neuropsychological testing or intensive behavioral interventions are required.

DBP is a board-certified medical subspecialty that cares for children with complex and severe DBP problems by recognizing the multifaceted influences on the development and behavior of children and addressing them through systems-based practice and a neurodevelopmental, strength-based approach that optimizes functioning.

DBPs care for children from birth through young adulthood along a continuum, including those suspected of, at risk for, or known to have developmental and behavioral disorders. DBPs often provide longitudinal care through parent and child counseling, care management and oversight, psychopharmacological management and consultation and coordination across systems of care.

The key aspects to this approach include:

1. Understanding the complex influences on the development and behavior of infants, children, adolescents, and young adults, and leading efforts to prevent disorders and promote optimal child development.

2. Partnering with families, other clinicians, and community providers, such as teachers and therapists to provide systems-based practice.

3. Using a neurodevelopmental, strength-based approach to optimize functioning.

Fundamental to DBP practice is the recognition that children live in families who live in communities that interact with large and complex systems of care; consequently, optimizing functioning includes understanding how a child is impacted and strengthened by each of these components. This approach, often referred to as the “eco-bio-developmental model,” encompasses an understanding of the environmental, psychosocial, socioeconomic, cultural, biological, and genetic influences on the development and behavior of children through young adulthood.

Improved clarity regarding DBP practice is necessary from a variety of perspectives. Students and trainees need a clear understanding of and exposure to DBP practice to consider it as a career choice. Payers and administrations need to understand the complexity involved in providing DBP care, and the resources needed to successfully support DBP practice. Other professionals, including primary care and other specialty providers, need to understand who to refer and when, and what to expect from a DBP referral.

We recommend that the definition of DBP practice outlined in this paper be adopted and shared with decision makers and leaders to support (1) adequate funding for DBP care and (2) enhanced DBP workforce development to improve access to high quality care. Addressing these issues is necessary for the health and viability of the field of DBP and is critical to ensuring positive life trajectories for all children, their families, and their communities. Ultimately, all patients and families deserve timely access to high quality, equitable DBP care.

We thank members of the Board of the Society for Developmental and Behavioral Pediatrics who are not authors on this paper, including Marilyn Augustyn, MD, Tanya Froehlich, MD, MS, Robyn Mehlenbeck, PhD, Alan L. Mendelsohn, MD, Britt A. Nielsen, PsyD, Neelkamal Soares, MD, Jennifer Walton, MD, MPH, and Kimberly Zlomke, PhD, BCBA-D, the entire membership of SDBP and Laura Degnon, CAE, for their careful review of this paper and valuable input.

ADHD

attention-deficit/hyperactivity disorder

ABP

American Board of Pediatrics

ACGME

Accreditation Council for Graduate Medical Education

ASD

autism spectrum disorder

CAP

child and adolescent psychiatry

DBP

developmental-behavioral pediatrics

DBPs

Developmental Behavioral Pediatricians

EPAs

entrustable professional activities

JDBP

Journal of Developmental & Behavioral Pediatrics

SBP

Society for Behavioral Pediatrics

SDBP

Society for Developmental and Behavioral Pediatrics

SDP

Society for Developmental Pediatrics