An Introduction to the Field of Developmental-Behavioral Pediatrics

Definition of DBP

The field of DBP was defined in an application to the American Board of Pediatrics (ABP) for subspecialty certification that was approved in 1998. DBP was conceived as a pediatric subspecialty with goals of research, teaching, advocacy, and clinical work in the domains of human development and behavior. All aspects of development—cognitive, social, emotional, and physical development—were acknowledged and seen as linked to contexts of family, school, and larger communities. Although the scope of practice may overlap with child neurology, child psychiatry, and child psychology, DBP was distinct because it retained its foundation in pediatrics, maintaining interest in high-prevalence, lower-severity conditions and typical developmental trajectories as well as in children with low-prevalence, high-severity conditions. Importantly, DBP is an interdisciplinary field. The interdisciplinary perspective can be seen, for example, in the authorship of the chapters in this book; clinical practices that use interdisciplinary teams; and membership of the primary professional organization, the Society for Developmental & Behavioral Pediatrics (SDBP), that includes physicians, psychologists, nurses, and others.

Key Perspectives and Values

DBP conceptualizes development and behavior as arising from biopsychosocial-ecological transactions (see Chapter 2 ) along a life-course timeframe (see Chapter 3 ). The life-course frame emphasizes that prevention and early intervention may substantially affect the developmental trajectory. DBP acknowledges that neurobiology shapes developmental outcomes, and the social context and developmental changes shape neurobiology (see Chapter 2 ).

DBP care is person centered and strengths based; it engages individuals in their own care, to the extent possible, recognizing their unique strengths as well as their needs. DBP clinical practice is family centered, utilizing shared decision making with families in the diagnostic and management phases. The contextual understanding recognizes the important role of culture (see Chapter 20 ) in the manifestations and understanding of illness and disability and in decisions about the acceptability of approaches to treatment. Cultural humility brings respect to different cultures and acknowledges socially embedded disparities in equity, diversity, and inclusion. DBP care necessitates close collaboration of the health care system with community resources and services. Many DBPs take on advocacy roles through engagement with practice associations, health systems, community-based organizations, or policymakers at local, state, and national levels. What is definitional about DBP is its unique perspective and not a set of organ systems, diagnoses, or practice settings ( ).

Changing Concepts of Children in Society

The term child comes from the Latin infans , which means “the one who does not speak.” Throughout history and across cultures, childhood has been an evolving concept. Childhood was defined as the period from birth to age 7 years in the Roman world and birth to age 18 years in the modern era. Table 1.1 demonstrates that child rearing has shifted perspectives over time with the rationales for the practices in Table 1.2 based on changing constructs about childhood ( ).

Agrarian cultures typically emphasized utilitarian functions for children (i.e., their ability to work). Urbanization led to changes in the state of childhood. As women in cities went to work to support their families, the children required childcare, nutritional infant formulas, and education. Yet, community-wide resources for women and children were limited due to their lack of political power, limitations on property ownership, excessive taxation, political injustice, and corruption.

In the late 17th and early 18th centuries the Enlightenment marked a change in the concept of the child. Philosophers such as John Locke (1632–1704) and Jean-Jacques Rousseau (1712–1778) emphasized the impact of experience on the developing child. This conceptualization accentuated the need to provide children with nurturing environments, education, and growth-enhancing experiences.

In the last century the concept of child agency gradually has taken hold, allowing for legal strategies to promote child welfare. An early instantiation was found in 17th-century France, where children were granted “minor rights” to education, among other areas. In 1908 the New York City Health Department founded the Bureau of Child Hygiene to address child health, including prenatal care, infant mortality, school inspections, and child labor laws. The League of Nations adopted the Declaration of the Rights of the Child in 1924, the first international treaty giving specific rights to children and responsibilities to adults. The United Nations (UN) Fund for Urgency for the Children was created in 1947 to promote humanitarianism and development aid and later became UNICEF (UN Children’s Fund). In 1959 the General Assembly of the UN adopted the Declaration of the Rights of the Child, which led to the International Charter of the Child Rights. All but one of the 195 UN members signed the document, and 192 ratified it. The United States signed but has not ratified it.

The Emergence of Pediatrics

During ancient history, health care for children had been the province of families and midwives. Physicians avoided the care of children because of prevailing social beliefs, limited medical training about children’s health, and the poor prognosis of many childhood diseases. Health care specifically for children emerged in the late 18th and 19th centuries. The first dispensary for children in London, England, was established in 1769. The first children’s hospital, L’hôpital des Enfants-Malades, was founded in Paris in 1802. The first children’s hospitals in the United States were established in 1855 in Philadelphia and New York City ( ). Abraham Jacobi (1830–1919), often considered the father of American pediatrics ( ), organized the first children’s clinic at the New York Medical College in 1860. He also organized the pediatric subsections for the American Medical Association (AMA) in 1880. He collaborated on public health efforts such as providing safe milk for poor infants in New York ( ).

Evidence of the crystallization of the field of pediatrics was the launch of Archives of Pediatrics , the first US journal to be devoted exclusively to children, in 1884 and the first professional society, the American Pediatric Society, in 1888. Pediatricians recognized that treating childhood diseases required public health as well as clinical interventions. In 1926 the Section on the Diseases of Children of the AMA voted in support of the reauthorization of the Sheppard-Towner Act, a modest federal maternal and child health program, on the same day that the AMA House of Delegates passed a resolution condemning the act. The conflict that followed ultimately led to the creation of the AAP in 1930 and subsequently the ABP. Public health advances promoted by pediatrics, such as sewage treatment, clean water, breastfeeding, and free medical care, all substantially reduced infant mortality and improved the health of children ( ).

Pediatrics has thrived since the 20th century in medical schools and children’s hospitals. With the advent of vaccines and antibiotics, the clinical focus of pediatrics is shifting away from infectious diseases to the management of chronic illnesses, including developmental disabilities, recognition of poverty and environmental causes of disease, and addressing the psychosocial determinants of health ( ).

Evolving Conceptualization of Disability

From antiquity through the Middle Ages in Europe, disabilities were interpreted metaphysically as punishment for sin or the work of evil, as opposed to biomedically ( ). A major shift began when a physician, Jean-Marc-Gaspard Itard (1775–1835), undertook the education of Victor, the Wild Boy of Aveyron, an abandoned and disabled child. He applied Enlightenment principles to educate the child but achieved only incremental success ( ). Itard’s student, Eduard Séguin (1812–1880), known as the father of special education, further popularized this concept of a comprehensive individualized educational program for children with disabilities. Maria Montessori (1870–1952), a child psychiatrist and first woman physician in Italy, based her educational philosophy on Séguin’s contributions. Center-based habilitation programs emerged, but in the second half of the 19th century they devolved into primarily custodial institutions with poor living conditions—some even practicing sterilization and euthanasia ( ).

After World War II, families championed the cause of disabilities through the establishment of advocacy organizations ( ). Formed in 1950, the National Association of Parents and Friends of Mentally Retarded Children, now known as The Arc, advocated for equal rights, improved education and health care for people with disabilities, taught skills that are important for independence and employment to individuals with disabilities, and encouraged research in the area of disability ( ). These efforts dovetailed with a changing legal landscape in public policy and education. A disability-oriented civil rights movement of the 1960s formulated a political agenda, focusing on overcoming the oppression, promoting independence and self-sufficiency, and advocating for social change. The social model of disability conceptualizes the cause of disability not as a health condition but as social, physical, and attitudinal barriers to participation in community life.

Evolving Concepts of Mental Health Disorders

Mental illness was at various times attributed to environmental causes such as loss of status or money, physiologic causes, astrologic alterations, possession by the devil, moral weakness, or divine punishment. Metaphysical treatments sought to correct the individual, such as inducing catharsis, submerging patients in ice baths, inducing vomiting, or bloodletting. Social exclusion and incarceration were other approaches that continue to this day as currently over 35% of prison inmates have a history of a mental health condition.

The Enlightenment dramatically altered the care of individuals with mental health disorders. Philippe Pinel (1745–1826), regarded as the father of modern psychiatry, promoted the method of moral management. The method included intense observation and conversation with individuals affected with mental disorders, supportive care such as hypnosis and relaxation, treatment in home-like settings, and work programs ( ). Attractive asylums were built that promised humane and effective treatments ( ). The institutions became overcrowded and returned to the use of restraints and shock therapies. The institutionalized population remained very high and conditions deplorable until the National Mental Health Foundation exposed the abuses in such institutions as the Byberry Hospital in Philadelphia in the 1940s ( ). In 1963 President John F. Kennedy proposed the development of comprehensive community mental health centers to reduce the number of individuals in custodial care and support the full spectrum of services from diagnosis through emergency care. Deinstitutionalization gained momentum; however, homelessness and crime are visible indications of the limitations of investment in these community-based programs.