CHAPTER 1

More than 50 years ago, Julius B. Richmond, MD, characterized child development as the basic science of pediatrics.1 The processes of child development and behavior affect all primary pediatric health care professionals^* and pediatric subspecialists, and these fundamentally differentiate pediatrics from all other areas of medicine. In addition to being experts in childhood wellness and illness, parents expect primary pediatric health care professionals to be experts in all aspects of childhood and adolescence, especially in the domains of development and behavior. Thus, clinical competence in child development and behavioral health is vital to the success of all pediatric health care encounters.

Despite child development’s role as the basic science of pediatrics, the Accreditation Council for Graduate Medical Education unfortunately requires all pediatric residents to receive a total of only 32 half-day sessions’ experience in developmental-behavioral pediatrics during their residency training.² Thus, even though most practicing primary care general pediatricians will rarely step inside a pediatric or neonatal critical care unit or even provide direct care for hospitalized patients after they have graduated from residency, they will rarely make it through even a half-day in their general pediatric practices without a question from a parent about a child’s development or behavior, for which, unfortunately, they are required to receive a total of only 16 days of training. This clearly represents a distressing mismatch between the amount of training and future demands in daily pediatric practice.³ Given this limited experience, it is not unexpected that surveys of pediatricians in practice continue to indicate that pediatricians feel ill-prepared in this distinguishing domain of pediatric practice.^4,5 In addition, family medicine residents, family and pediatric nurse practitioners, and physician assistants, who will provide medical homes for at least one-third of all children in the United States,⁶ generally receive little, if any, training in this basic science. As illustrated in Table 1.1, and even more concerning in this setting of limited training, developmental disorders are the most prevalent chronic medical conditions encountered in primary care, and psychosocial and behavioral issues are even more ubiquitous in day-to-day pediatric practice.^7–9

^a Data derived from Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics. 2011;127(6):1034–1042; Christensen DL, Baio J, Van Naarden Braun K, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2012. MMWR Surveill Summ. 2016;65(3):1–23; and Centers for Disease Control and Prevention National Center for Health Statistics. http://www.cdc.gov/nchs. Accessed January 18, 2018.

Of the 118,292 pediatricians currently certified by the American Board of Pediatrics, only 775 are subspecialty board-certified in Developmental-Behavioral Pediatrics and only 255 are subspecialty board-certified in Neurodevelopmental Disabilities.¹⁰ This does not represent 1,030 different subspecialists, as some individuals have both certifications. To illustrate the critical dearth of developmental-behavioral subspecialists, consider that congenital heart disease affects approximately 1% of the pediatric population. Currently, there are 3,218 board-certified pediatric cardiologists to care for these children.¹⁰ However, if this is the number of subspecialists required to provide subspecialty care for this 1% of the population, then it would require nearly 80,000 board-certified developmental-behavioral pediatricians (not the current 775) to provide the same level of subspecialty care for the approximately 25% of the pediatric population with developmental-behavioral concerns (see Table 1.1).

This combination of a very high prevalence of developmental-behavioral disorders and an enormously critical shortage of subspecialists to whom patients may be referred creates extremely long waiting lists at tertiary care developmental-behavioral evaluation centers; this makes subspecialty referral a futile proposition for the vast majority of children with developmental or behavioral concerns.³ Thus, most children with developmental or behavioral concerns must be managed within their primary care medical homes. Clinical judgment and confidence in evaluation and management of developmental-behavioral concerns need to be considered as basic to general pediatric practice as are evaluation and management of asthma and other common chronic medical conditions encountered daily in pediatric practice.3

This second edition of American Academy of Pediatrics Developmental and Behavioral Pediatrics continues to represent a cooperative effort of the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics and Council on Children With Disabilities. While it certainly cannot provide the experiential learning that an expansion of required subspecialty exposure to developmental-behavioral pediatrics during pediatric or family medicine residency training or in the training of future primary care nurse practitioners or physician assistants would provide, given the crucial need to enhance the education of all primary pediatric health care professionals in this basic science of pediatrics, this manual attempts to blend the overlapping perspectives of both Neurodevelopmental Disabilities and Developmental-Behavioral Pediatrics with the goal of improving care for all children.

Finally, this manual is intended to be neither an exhaustive reference geared for the subspecialist nor a cursory introductory list of developmental and behavioral pediatric topics. Instead, this expanded second edition aims to be a resource that provides the essentials of what all primary pediatric health care professionals need to know to successfully care for children with developmental and behavioral concerns in their practices and to identify those who truly require subspecialty referral. It is hoped that with the assistance of this manual, primary pediatric health care professionals will gain more confidence in evaluating and managing children with developmental and behavioral concerns and provide evidence-based developmental-behavioral pediatric care within the medical home.

References

1.Richmond JB. Child development: a basic science for pediatrics. Pediatrics. 1967;39(5):649–658

2.Accreditation Council for Graduate Medical Education Program Requirements for Graduate http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/320_pediatrics_2017-07-01.pdf?ver=2017-06-30-083432-507. Accessed January 18, 2018

3.Voigt RG, Accardo PJ. Formal speech-language screening not shown to help children. Pediatrics. 2015;136(2):e494–e495

4.Sices L, Feudtner C, McLaughlin J, Drotar D, Williams M. How do primary care physicians identify young children with developmental delays? A national survey. J Dev Behav Pediatr. 2003;24(6):409–417

5.Halfon N, Regalado M, Sareen H, et al. Assessing development in the pediatric office. Pediatrics. 2004;113(6)(suppl 5):1926–1933

6.Phillips RL, Bazemore AW, Dodoo MS, Shipman SA, Green LA. Family physicians in the child health care workforce: opportunities for collaboration in improving the health of children. Pediatrics. 2006;118(3):1200–1206

7.Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics. 2011;127(6):1034–1042

8.Christensen DL, Baio J, Van Naarden Braun K, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2012. MMWR Surveill Summ. 2016;65(3):1–23

9.Centers for Disease Control and Prevention National Center for Health Statistics. http://www.cdc.gov/nchs. Accessed January 18, 2018

10.American Board of Pediatrics, Inc. Pediatric Physicians Workforce Data Book 2015-2016. Chapel Hill, NC: American Board of Pediatrics, Inc; 2016

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