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Developmental Behavioral Pediatrics: Central to Pediatrics

September 26, 2023

Commentary From the Section on Developmental Behavioral Pediatrics

The American Academy of Pediatrics (AAP) Section on Developmental and Behavioral Pediatrics (SODB) began in 1960 for members primarily interested in developmental and behavioral aspects of pediatric care. From its founding, it has been a section that has included both subspecialists and primary care providers (about half of each). The mission of the SODBP is to strengthen collaboration between primary care pediatricians, developmental and behavioral subspecialists, and families to ensure that children receive comprehensive, high-quality developmental and behavioral pediatric care. For this review, I surveyed our section membership for suggested seminal papers, reviewed past award winners and their work, and sent drafts of this commentary to prior chairs of the SODBP for review.

Developmental Behavioral Pediatrics: Central to Pediatrics

Peter J. Smith, MD, MA, FAAP

Affiliation: Associate Professor, Section of Developmental and Behavioral Pediatrics, University of Chicago

Highlighted Articles From Pediatrics

  1. McPeak W. Some pediatricians’ views concerning problems of handicapped children. Pediatrics. 1948;1(2):214-220
  2. Brazelton TB. The early mother-infant adjustment. Pediatrics. 1963;32(5):931-937
  3. Richmond J. Child development: a basic science for pediatrics. Pediatrics. 1967;39(5):649-658
  4. Crocker AC. Therapeutic trials in inborn errors: an attempt to modify Hurler’s syndrome. Pediatrics. 1968;42(6):887-888
  5. Carey WB, Fox M, McDevitt SC. Temperament as a factor in early school adjustment. Pediatrics. 1977;60(4):621-624
  6. Palfrey JS, Levy JC, Gilbert KL. Use of primary care facilities by patients attending specialty clinics. Pediatrics. 1980;65(4):567-572
  7. Cronk C, Crocker AC, Pueschel SM, et al. Growth charts for children with Down syndrome: 1 month to 18 years of age. Pediatrics. 1988;81(1):102-110
  8. Tanner JL, Dechert MP, Frieden IJ. Growing up with a facial hemangioma: parent and child coping and adaptation. Pediatrics. 1997;101(3):446-452
  9. Blum NJ, Taubman B, Nemeth N. Relationship between age at initiation of toilet training and duration of training: a prospective study. Pediatrics. 2003;111(4):810-814
  10. Bridgemohan C, Bauer NS, Nielsen BA, et al. A workforce survey on developmental-behavioral pediatrics. Pediatrics. 2018;141(3):e20172164
  11. Hyman S, Levy S, Myers M, et al. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics. 2020;145(1);e20193447
  12. Weitzman CC, Baum RA, Fussell J, et al. Defining developmental-behavioral pediatrics. Pediatrics. 2022;149(4):e2021054771

The celebration of the Diamond Jubilee of Pediatrics with the naming of the landmark papers that have been published in its pages is a wonderful opportunity to reflect on the progress made in the field of developmental-behavioral pediatrics (DBP) over the past 75 years. Much has changed over that period (including the name of the field), but much has remained constant, especially 3 main themes: (1) child development is central to all work in pediatrics; (2) research in child development is crucial and needs to be tied to helping children and their families; and (3) clinical care for children with DBP conditions is under-valued (both for DBP specialists and for primary care clinicians), and there are too few subspecialty clinicians.

It is striking to read the results of William McPeak’s survey of the leaders of pediatrics (drawn from department chairs and leaders in the AAP) completed in 1947: many of the findings would be the same if that survey was repeated today.1 For example, “visible” impairments are given more attention (and funding) than “invisible” conditions. Also, the different emphases of pediatrics departments on research to prevent future impairments versus those of clinicians who focus on caring for children with DBP conditions was already present: “Professors in pediatric departments are relatively more concerned about needs for research and education in handicapping diseases, while practitioners seem more impressed by shortages of facilities for direct care of individuals.” Most practitioners in DBP today would feel the same now.

An example of the importance of noting the key aspects of relationships, especially the relationship between a mother and her newborn baby, and the impact that these have on outcomes is well illustrated in an early paper by T. Berry Brazelton.2 Dr. Brazelton pioneered careful observations of newborns from their first moments of life, and he helped to develop an entire community of clinicians and researchers who did not dismiss (as many did) the importance of the early interactions of mother and infant. The work of that community has transformed both the care models and attitudes about early childhood, both within the hospital and in outpatient clinics.

Julius Richmond, who later served as US Surgeon General and Assistant Secretary of the Department of Health and Human Services, wrote cogently in 1967 about child development being central to all questions in pediatrics.3 He argued that pediatricians were uniquely qualified to lead the care and research in child development. He also noted the false assumptions of those who prioritized “hard data” versus “soft data,” pointing out that “the scientific method demands excellence in experimental design, data collection, and data analysis. The question, therefore, is one of excellence—not of hardness or softness.” Dr. Richmond’s insights are as timely today as when he wrote them.

In 1968, Allen Crocker, a pioneer in the understanding of inborn errors of metabolism (especially mucopolysaccharidoses) outlined a straightforward set of 4 parameters for a therapeutic trial for inborn errors of metabolism.4 It is of note that his comments are about a “negative” trial (of another team, who he congratulates for their rigor), which highlights the ongoing need for the reporting of therapeutic trials that are unsuccessful. His parameters are good guides that could be applicable to current therapeutic trials, and he advocated for the “excellence” that Dr. Richmond demanded.

A central understanding of child development would be inadequate without the insights gained from the teams that studied and reported on temperament, such as William Carey and his team.5 In working to create validated instruments that were more practical to use in primary care, Dr. Carey and his team were early leaders in the quest to measure different aspects of child development (often borrowed from theories in child psychology) in real populations and to assess their impact on clinically significant outcomes. In addition, their paper also helped to inform pediatricians about temperament, which was a concept not commonly understood in pediatrics at the time.

As some pediatric subspecialists assumed the leading role in managing the medical care of children with chronic conditions, the primacy of the general pediatrician in the provision of longitudinal care decreased. In 1980, Judith Palfrey and colleagues documented this problem and advocated that all children should have a primary medical home that coordinated all aspects of care.6 Dr. Palfrey and her team recognized that although subspecialists provided excellent care within their scope, children and families suffered from a lack of well-child care, anticipatory guidance, and serial developmental and behavioral assessment.

In 1988, Christine Cronk and her team across multiple medical centers championed the use of specialized growth charts for unique populations of children, such as children with Down syndrome.7 It was a crucial advance not only for helping to move the primary care of children with Down syndrome from the specialty clinics to primary care, but also for helping the field of pediatrics to reframe the perspective of caring for these children to enhance their growth and positive development. This was a tremendous move away from prior perspectives that had a more negative view of the quality of life of children with Down syndrome.

Another important paper that helped change perspectives by focusing on the lived experience of children and their families was written in 1998 by J. Lane Tanner and colleagues.8 They demonstrated that facial hemangiomas should not be dismissed as “benign” for the children and families who live with them, even though they do not lead to medical complications. They are difficult for the children and families to experience, and pediatricians need to be aware and not ignore these real difficulties. This is a paper that reminds all clinicians that the “medical” part of care and research may not highlight the most important impact of a condition for children and families.

As a field, DBP clinicians and researchers often have applied rigorous analysis to common issues that arise in raising children. An excellent example of this type of analysis is the 2003 paper by Nathan Blum and colleagues that examined in a controlled study the process of toilet training.9 Their careful protocol, and straightforward conclusions offered, for the first time, an evidence-based approach to a set of questions that are confronted by almost all parents.

As any currently practicing primary care clinician knows, the referral wait times for DBP are measured in months. It has been known that the field was understaffed, but it was the 2018 paper by Carolyn Bridgemohan and a multisite team of collaborators that documented the true extent of the crisis.10 Dr. Bridgemohan was a leader in DBP in education, research, and clinical care, and this paper is one of the many legacies that she left the field in her too-short lifetime.

The referrals to DBP have increased over the past 25 years in large part due to the increased recognition and identification of children who meet criteria for autism spectrum disorder (ASD). In 2020, Susan Hyman and Susan Levy were the lead authors of the AAP revised policy statement on ASD.11 This extensively referenced guide took years to assemble (“like birthing an elephant”) and is an excellent review of the identification, evaluation, and management of children with ASD. It should be the starting point of any educational programs in ASD for years to come.

Finally, after many years of debate and discussion (sometimes heated), the field of DBP is becoming more unified in its professional understanding of itself. Carol Weitzman and her team of collaborators recently published a seminal paper that literally defines DBP.12 This is an important step for the field as it confronts the workforce shortage and the many different causes for that shortage. The SODBP has developed an action plan to address this workforce shortage, which will be implemented starting later in 2023 (more information will be available shortly).

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