Primary care is the label applied to community-based medical settings that offer first-contact personal health care that is comprehensive and longitudinal (1). Most American children make at least one primary care medical visit annually (2), and parents look to pediatric primary care providers (PCPs) as resources for addressing psychosocial problems (3). The public health relevance of pediatric mental health problems is increasingly being appreciated; it is estimated that between 15% to more than 25% of pediatric patients have a mental health (MH) problem or disorder (4,5). The prevalence of MH problems of concern to pediatricians would be even greater if the MH needs of the parents of pediatric patients (e.g., maternal depression) were considered within the purview of pediatric PCPs (6). Due to the high prevalence of MH concerns in children and adolescents and the frequency of their contact with PCPs, it stands to reason that pediatricians and other PCPs are important resources for identification and early management of common MH problems and disorders.

Mental health disorders are among the most disabling of pediatric conditions, and are associated with interpersonal difficulties, poor school performance, and school absenteeism, with one-third of all school days missed by adolescents being MH related. It is therefore not surprising that psychosocial problems are the most common chronic conditions presenting during pediatric ambulatory health visits, with a broad range of severity and high rates of comorbidity, comparable to chronic conditions such as asthma and diabetes. Not only are MH disorders highly prevalent across the lifespan, but early onset is more the rule than the exception, with pediatric psychiatric disorder being powerfully predictive of adult disorder and impairment. As demonstrated by the National Comorbidity Study, the onset of approximately half of all MH disorders occurs at or before age 14, with approximately three of four MH disorders beginning by age 24 years (7).

Despite a growing awareness of the biopsychosocial model of health and an appreciation that physical and mental health are inextricably linked, our health care delivery system is split into parallel systems of care depending on whether a problem is conceptualized as physical (general medical conditions) or psychological (MH disorders). While it is true that most professionals, when pressed, will agree that health is a unitary construct that cannot be parsed into physical and mental components, our behavior, the organization of health care, the systems of healthcare reimbursement, and the behaviors of our patients suggest otherwise. Whether a disorder is conceptualized as physical or mental thus has profound implications for how and where the disorder is cared for, which professionals are expected to bear primary responsibility for care delivery, and how that care is reimbursed. Due to the persistent stigma associated with MH disorders, there are additional societal implications resulting from whether a disorder is considered to be a general medical condition or a MH disorder. In contrast to physical disease, MH disorders are often viewed by our society as being under the voluntary control of the affected individual, the consequence of individual weakness, inadequacy, or moral failing, and thus associated with stigma, shame, and embarrassment.

Physical symptoms are a common presentation of psychiatric disorder in general medical settings, with disorders conceptualized as mental (e.g., anxiety and depressive disorders) commonly presenting to PCPs and medical specialists
with very real and disabling physical complaints and distress (functional abdominal pain and headaches) (8,9,10). Such patients tend to utilize more health services and can be quite costly to society (11). Potentially serious physical health consequences have also been associated with pediatric MH disorders, most notably increased risks of suicide, violence, and accidental injury, as well as overweight, early pregnancy and alcohol, drug, and tobacco abuse (12,13,14,15).

It is also well known that physical disease is a significant risk factor for the development of emotional and behavioral problems, with several studies documenting that chronic physical disorder is a risk factor for MH problems and disorders in both community-based and clinical samples across the lifespan (16,17,18,19). In part due to the success of modern medicine, chronic physical illness is a growing problem; approximately 1–3% of all youth suffer from significant functional impairment resulting from chronic physical illness (17). Physical diseases or injuries that affect the brain (e.g. epilepsy, cerebral palsy, head trauma) are especially potent risk factors for comorbid emotional, behavioral, and learning problems (19,20). The presence of a MH disorder can also influence the course of physical disease, as demonstrated in juvenile diabetes, where comorbid depression has been identified as an independent risk factor for the development of diabetic retinopathy (21), repeat hospitalization (22), overall adaptation to the disease (e.g., adherence to treatment), and possibly metabolic control (23). From this, it should be evident that disorders considered to be mental can have profound physical health consequences and vice versa.

Research has demonstrated the efficacy of a growing number of treatments for common pediatric MH disorders (24), but most affected youth do not receive any treatment (4). Of those who do receive services, many are not treated in accordance with available best practices, with considerable gaps existing between research-driven knowledge and routine clinical practices (25,26). Interventions that have been proven efficacious for attention-deficit/hyperactivity disorder (ADHD) (25), anxiety disorders (27,28,29), and depressive disorders are generally not systematically or effectively applied on the population level, with routine care often falling short of best practices (30). Finding the means to translate advances in treatment efficacy into practical effectiveness strategies will thus be necessary to maximize public health benefits of new advances in therapeutics, and will likely require commitment, multidisciplinary collaboration, and systemic changes in the way that professionals in primary care and specialty MH care work together (31,32,33). One example of such an initiative to improve the quality of care for pediatric MH disorders in pediatric primary care settings is the effort by the American Academy of Pediatrics (AAP) to develop practice guidelines for the diagnosis and management of attention-deficit/hyperactivity disorder (34,35).

The high prevalence of psychosocial problems in children within pediatric primary care settings was described by Haggerty in 1975 and termed the new morbidity. Due in part to the successes in preventive medicine (e.g., immunizations) and medical therapeutics (antibiotics), the nature of the pediatric needs of children and their families has changed, resulting in a growing emphasis on developmental and behavioral issues in pediatric care. Much of this alteration in practice pattern was also the result of a changing environment. Major changes in family, school, and neighborhood contexts over the past few decades resulted in an exacerbation and increase in developmental and behavioral problems along with a dramatic decrease in formal and informal social networks that might have in the past provided advice and guidance on their management.

The field of developmental-behavioral pediatrics (DBP) arose from the need to enhance the capacity of pediatricians to identify, manage, and when necessary, refer children with developmental and behavioral concerns and to implement effective prevention approaches. The goal was not to create a cadre of independent clinical subspecialists which might compete with child and adolescent psychiatrists, but to produce academic leaders and researchers that can enhance the training of general pediatricians so that they will be better prepared to address the developmental and behavioral needs of their own patients.

DBP focuses on the evaluation and management of common behavioral problems such as temper tantrums, attention-deficit disorders, or sleep problems, common developmental disabilities such as mental retardation, and physical complaints best addressed via a biobehavioral approach, such as recurrent abdominal pain. DBP aims to be eclectic and committed to multidisciplinary collaboration, with developmental-behavioral pediatricians striving to integrate a wide range of complementary theories derived from the medical, biological, behavioral, and social sciences, and drawing upon clinical skills and research approaches that are otherwise associated with a range of disparate disciplines. As a result, there is significant overlap between conditions appropriate for management by developmental-behavioral pediatricians and other disciplines, such as child and adolescent psychiatry, neurodevelopmental specialists, pediatric neurologists, and child psychologists.

As the field of DBP matured, it became desirable to have a recognized subspecialty so that there could be a core faculty within academic medical programs to organize the teaching of medical students, residents, fellows, and other allied health professionals, to conduct relevant research, and to assist in the delivery of clinical care. The Society for Developmental and Behavioral Pediatrics (initially called the Society for Behavioral Pediatrics) was formed in 1982; it is an international, interdisciplinary organization with approximately 750 members whose goal is to improve the health of infants, children, and adolescents by promoting research, teaching, and clinical practice in developmental-behavioral pediatrics (www.sdbp.org). SDBP has a well regarded professional journal, Journal of Developmental and Behavioral Pediatrics (www.jdbp.org), which is devoted entirely to the developmental and psychosocial aspects of pediatric health care and written for physicians, psychologists, and other clinicians and researchers.

In 1999, the field of developmental-behavioral pediatrics was approved as a subspecialty by the American Board of Medical Subspecialties and the first subboard of DBP within the American Board of Pediatrics was established to work with the Residency Review Committee to develop guidelines for subspecialty fellowship training and to develop an examination for certification of subspecialists in DBP. The first applications for accreditation of Fellowship Programs in DBP were accepted by the Accreditation Council for Graduate Medical Education in October 2002. Accredited fellowship programs in DBP accept trainees upon completion of an accredited pediatric residency program and are 3 years in duration. The fellowships comprise experiences in patient care to lead to the development of clinical proficiency, involvement
in community or community-based activities, and development of skills in teaching, program development, research, and child advocacy. The first board certification examination in DBP was administered in November 2002, with the first certified subspecialists in the field in March 2003.

Both DBP and child and adolescent psychiatry are relatively young fields that share many commonalities. While DBP is firmly identified with traditional medicine by virtue of its subspecialty relationship to pediatrics, and child and adolescent psychiatry typically is considered to fall under the rubric of “mental health,” DBP is increasingly integrating the insights offered by modern psychiatry and child and adolescent psychiatry is increasingly acknowledging its medical roots and connections to both pediatrics and psychiatry. The popularity of “triple board” training in pediatrics, psychiatry, and child and adolescent psychiatry, an alternative training pathway that also reflects a growing appreciation of the need to bridge the apparent gap between pediatric physical and mental health care, also validates the importance of active collaboration among the disciplines.

Although collaboration between pediatrics and psychiatry has been a topic of considerable interest and discussion for at least half a century, the hope of integrating MH services into pediatric general medical settings has yet to be realized. Parallel systems of care for physical and MH problems persist despite governmental recommendations to better integrate existing research-based knowledge into routine clinical practice (33), and existing models of reimbursement impair rather than facilitate meaningful collaboration. The scope and impact of pediatric emotional and behavioral problems nevertheless dictate that a response limited to the specialty MH sector is unlikely to prove successful in the short or long term, and is particularly unsuited to prevention efforts. Success in addressing the public health challenge presented by pediatric MH disorders will likely depend on multidisciplinary collaboration between child and adolescent psychiatrists, developmental-behavioral pediatricians, general pediatricians, family physicians, and affiliated MH professionals such as nurses, psychologists, and social workers, as well as efforts that span existing parallel systems of physical and MH care and reimbursement.

The public health importance of the primary care setting in the identification and management of common pediatric MH disorders is well recognized (3,33,36). PCPs manage the vast majority of recognized psychosocial problems (4) and prescribe the majority of psychoactive medications to American children and adolescents (32,37). Psychosocial problems are increasingly becoming the major focus of primary pediatric care for school-age children, but surveys of pediatricians suggest that they are among the most time consuming and frustrating problems to deal with in routine practice. PCPs report inadequate training in the management of pediatric MH problems (4,38), and low rates of PCP recognition of youth with MH disorders are the rule rather than the exception (3,36,38). Standardized assessment tools and/or diagnostic criteria are not in common use by PCPs in most clinical settings (39,40).