A Proposal to Change Medical Training Will Affect Autism Care

In the U.S., almost 20 percent of children have developmental delays, including autism spectrum disorder (ASD), ADHD, learning disabilities or speech and language disorders. These disorders are usually diagnosed in childhood and have specific and time-intensive treatments based on severity.

The prevalence of some of these disorders is rising, including autism. The Centers for Disease Control and Prevention recently announced that an all-time high of one in 36 children have this condition. General pediatricians play a crucial role in identifying early signs of these conditions and making referrals based on developmental screening and surveillance, because early intervention can change a child’s prognosis.

Once a general pediatrician suspects a diagnosis of autism or ASD, they will often refer families to developmental and behavioral pediatricians like us for more specialized or intensive evaluation, as well as ongoing care. But our field is in trouble, and if it doesn’t survive, general pediatricians will have to manage developmental conditions, on top of everything else they already do, with less comprehensive training. We worry that changes affecting our field will leave many children without the most thorough care that developmental and behavioral pediatrics can offer.

Currently, board-certified developmental and behavioral pediatricians are responsible for teaching pediatric residents about child development and developmental disorders. Studies have estimated that one in four families have concerns about their child’s development, so the training that clinicians with our depth of experience and knowledge provide is critical. But the governing body that sets those requirements, the American College of Graduate Medical Education, wants to eliminate this requirementturning that training over to general pediatricians instead. We anticipate this move will lead to delayed and insufficient diagnoses and treatments for children.

As part of this training, we spend one or two months with these residents to help them both understand disorders like autism and how to recognize early signs of it. We teach them about evidence-based treatment recommendations, including ones that we use regularly. Even though it’s not enough time to share all we know, developmental and behavioral pediatricians serve to help general pediatricians recognize these childhood disorders and refer them for evaluation more confidently.

We do not ask general pediatricians to be the sole educators of how to treat childhood cancer, seizures or diabetes, and yet this is what the college is proposing with regards to developmental disorders.

We understand why the college wants to do this; there are too few of us, and allowing general pediatricians to teach residents allows flexibility for programs that cannot hire from the already scarce pool of developmental and behavioral pediatricians. But this proposal feeds into a bigger problem within pediatrics: most subspecialists make less money than general pediatricians.. To make accurate diagnoses takes time and collaboration with other disciplines such as psychology, speech and language pathology, occupational therapy, and educators. This means we see fewer patients, and we cannot always bill for this time. In addition, developmental and behavioral pediatricians do not have the insurance reimbursement rates of surgical specialties or pediatricians who see higher volumes of patients. This means that few pediatricians choose our path, either because the salary is inadequate to repay six-figure medical school loans, or they haven’t been exposed to it, so do not see the rewards it brings over time. The ACGME’s proposal will not improve these issues and almost certainly will add to the shortage of developmental and behavioral pediatricians.

Our specialty has grown because of the success of vaccines and antibiotics, changing the focus of pediatrics from battling infectious disease to keep children alive to optimizing those lives through monitoring child development and managing mental and behavioral health issues. To better manage these issues required a new subspecialty outside of general pediatrics and child psychiatry, one that has expertise in advocacy, expected and unexpected streams of development, learning and emotional health.

What the ACGME is proposing will leave the families of neurodivergent children with fewer resources for comprehensive diagnosis and ongoing care than they already have. The proposal has implications for the educational system and other service organizations for individuals with developmental delays and disorders as children and families may not be able to access special services without appropriate and accurate diagnoses.

Furthermore, general pediatricians have more than their fair share to do; they are managing the pediatric mental health crisis, the respiratory “tripledemic” and well-child care that went by the wayside during the COVID-19 pandemic. Pediatricians have been forced to learn as they go with the pandemic and behavioral health crisis, managing mental health issues without enough community therapists or specialized training in more complex medication management. They cannot do everything all at once, and adding in more work diagnosing and treating developmental delays and disabilities will inevitably lead to moral distress and eventually burnout.

Other options are available. First, technology allows education and clinical mentorship across pediatric residency systems. ECHO Autism is an option for virtual mentoring and education that democratizes knowledge and allows clinicians to access specialty care in developmental and behavioral pediatrics. Pediatricians-in-training could meet virtually with specialty teams on a monthly basis to discuss care of children who need assessment and support for developmental and behavioral health issues. They could take these recommendations back to the children and families while also learning about clinical management and care for children with developmental delays and disabilities. This also establishes clinical mentorship with developmental and behavioral pediatricians throughout their training.

The Society for Developmental and Behavioral Pediatrics has provided information for how pediatricians, providers and families may advocate for the continued inclusion of board-certified developmental and behavioral pediatricians in residency programs.

But health care systems and insurance companies must also prioritize developmental and behavioral health by paying clinicians with this expertise higher salaries and reimbursements than we already receive. Large health care systems need to advocate at the state level to increase insurance reimbursement for the care we provide. Giving any child less than the standard, and ideally the best possible, treatment would not be acceptable for cancer, and it is not appropriate for developmental delays and disabilities. Our children live longer lives than ever before, and we strive to support neurotypical as well as neurodivergent children so that they too, can have fruitful adulthoods and a meaningful place, as they define it, in society.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those ofScientific American.