The Future of Behavioral Pediatrics Research: Moving Right Along

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830 PEDIATRICS Vol. 90 No. 5 November 1992

The

Future

of Behavioral

Pediatrics

Research:

Moving

Right

Along

Moms Green, MD5; W. Thomas Boyce, MDX; Jack W. Finney, PhD;

Sheridan Phillips, PhDII; and Barry S. Zuckerman, MDiI

Although faculty in the biobehavioral and devel-opmental aspects of pediatrics has increased

substan-tially in the past decade in response to needs in

pediatric education, care, and research, there

contin-ues to be a serious shortage of those trained in the

requisite methodology. With few exceptions,

depart-ments of pediatrics are not yet prepared to provide 3

to 5 years of rigorous fellowship training in behavioral pediatrics research under the mentorship of

estab-lished researchers. This widely recognized gap

be-tween the need for a better understanding of the

causes of behavioral and developmental morbidity

and the capacity to acquire that knowledge through

research led to the convening of a workshop in the

future of behavioral pediatrics research held May 22

to 24, 1989, in Columbia, MD.

The range of intellectually stimulating

presenta-tions at the workshop provided a glimpse of the new

frontiers in behavioral pediatrics that have been made

possible by the recent advances in neurobiology,

mo-lecular biology, genetics, and other basic sciences. If time had permitted, equally inviting areas of

investi-gation, such as maternal-infant interaction, family

dysfunction, divorce, assessment of risk and health,

the ecology of childhood, school reform, child abuse,

intervention strategies, the nosology of behavioral/

developmental problems, and disadvantaged youth

could also have been highlighted.

THE NEED FOR AN IDENTITY

The scientific credibility, coherence, vitality, and

growth of any discipline, including behavioral

pedi-atrics, require a theoretical base that serves to explain

events, order observations, and generate new

hy-potheses for empirical research. Such constructs

in-form both the clinician and the investigator.

Accord-ingly, a central goal of the workshop was to develop

a clearer identity for behavioral pediatrics, one that

encompasses a special knowledge base and arena of

research interest.

The current theoretical background for

biobehav-ioral pediatrics is eclectic, derived from many medical, biological, behavioral, and social sciences. Although

the recombinant product of these disciplines has been

eDepartment of Pediatrics, Indiana University School of Medicine and the James Whitcomb Riley Hospital for Children, Indianapolis; Child Study Unit, University of California-San Francisco; §Department of Psychology, Virginia Polytechnic and State University, Blacksburgj lDepartment of Psy-chology, University of Maryland School of Medicine, Baltimore; and #{182}Divi-sion of Developmental and Behavioral Pediatrics, Boston City Hospital, MA.

Received for publication Jul 22, 1991; accepted May 15, 1992.

useful, the process has been somewhat diffuse. What

seems required at this time is a clearer identify

an-chored by concepts that integrate the topics enumer-ated in Table 1.

A distinct identity is important not only for behav-ioral pediatric scientists but also to further the

recog-nition of the field among colleagues in the more

established pediatric subspecialties, such as pediatric oncology, cardiology, or infectious disease, as well as

among scholars in other disciplines. Identity is also

an important magnet in attracting bright trainees, the support of funding agencies, time, and space-essen-tial academic nutrients for the continued vitality and growth of the field.

Like research in other domains of pediatrics,

be-havioral pediatrics research is rooted in clinical

obser-vation and motivated by the determination to

en-hance the pediatrician’s efficacy in prevention, health promotion, intervention, or treatment.

A number of years ago, the American Academy of

Pediatrics Committee on the Psychosocial Aspects of

Child and Family Life viewed the scientific and

ex-periential knowledge base applicable to pediatric

practice as including normal growth and

develop-ment; adaptive and maladaptive psychosocial

devel-opment; the nature of parent-child and family

rela-tionships; the relation of child care and parenting

practices to different family styles and ethnic and

cultural backgrounds; reactions of children of various ages to illness, death, and other discontinuities; the nature and significance of psychometric tests to assess

status, aptitude, and achievements; opportunities for

preventive intervention in primary care and counsel-ing at-risk families; and principles of the psychother-apeutic role of the pediatrician.1

While some of these broad interests are shared by

our colleagues in child psychiatry and pediatric

psy-chology, the behavioral pediatrician is identified, as

are other pediatric subspecialists who work in

pedi-atric settings, as a general pediatrician with special clinical expertise and research interests.

Thus, the behavioral pediatrician is concerned with

the prevention, early detection, and management of

psychosocial problems pertinent to optimal child and

family health and development. These activities

in-dude pediatric anticipatory guidance, support, and

appropriate assistance during family crises such as

the birth of a premature or handicapped infant,

di-vorce, severe family illness, or death. In addition, the

behavioral pediatrician has an important role in the

evaluation and treatment of common behavior

dis-orders such as temper tantrums, breath-holding

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spells, hyperactivity, or sleep problems;

develop-mental disabilities such as mental retardation; and

somatic complaints of psychosocial etiology such as

failure to thrive, persistent headache, fatigue, or

ab-dominal pain. Finally, the behavioral pediatrician

plays a role in managing instances of child abuse or neglect; in helping children and parents cope with physical illness, especially a long-term or fatal disease; in preparing children for hospitalization or surgery; in addressing the challenges of substance abuse; and in dealing with difficulties in school.

The chief distinction between behavioral pediatrics

research and traditional biological research in

medi-cine or psychosocial investigations in psychology and

sociology lies in the focus of the former on the bio-behavioral interface. While the destiny of behavioral pediatrics lies firmly within the mainstream of pedi-atric research and practice, enriched by its close link-ages with other pediatric investigators, it also needs a

constant hematinic infusion from social and

behav-ioral scientists.

The workshop presentations reinforced the

devel-opmental roots of behavioral pediatrics research and

the growing relevance of the process of adaptation.

The present pediatric era is characterized by an

aug-mented interest in helping children and their families master the psychosocial and developmental, as well as the biological, stressors in their lives. Consequently, this workshop was liberally sprinkled with the vocab-ulary of stress, adaptation, and coping research (eg, risk factors, noxious stimuli, coping, vulnerability, resiliency, protective factors, and interventions).

INITIATIVES FOR THE FUTURE

Challenged and given pause by the complexity and difficulties of mining the research opportunities in this field, the workshop participants posed four key

questions: Where do we go from here? How do we

build further capacity? What is realistic? What would be ideal?

While the answers need to be delineated further,

the following initiatives, also listed in Table 2, would be highly facilitative.

:i. Establishment of networks or research consortia for investigators in behavioral pediatrics with common re-search interests. Many of the most important questions in behavioral pediatrics require not only longitudinal observations but also large populations of children.

TABLE 1. The Scope of Behavioral Pediatrics

1. Biology and behavior

2. Health and illness

3. The child, the family, and the community 4. Individuals and populations

5. The brain and the mind

6. Related disciplines, eg, psychology(developmental, behavioral, social, cognitive), epidemiology, ethnology, anthropology, nursing, sociology, education, statistics, child psychiatry, social work, and the basic biological sciences

7. Prevention, health promotion, intervention, and treatment 8. Multiple problems in the same child or family

9. Vulnerability and resiliency

10. Cross-sectional and longitudinal observations 11. Naturalistic observation and empirical research 12. Office, clinic, hospital, home, school, and other settings

Certain studies, such as those examining

low-mci-dence conditions, require the availability of popula-tions from multiple sites. Under these conditions, it is

important to have funding available to support the

development of stable, collaborative ties among

in-vestigators in several locations.

Support provided by the W. T. Grant Foundation,

for example, has enabled multidisciplinary groups of

investigators to meet regularly to critique their

re-search, share new methodologies, learn of additional funding sources, and avoid academic isolation. Such consortia have included those on chronic illness, stress-buffering, divorce and children, adolescent

be-reavement, black adolescents, psychobiological

vari-ables of stress, and school-based promotion of social

competence. Networks of scholars serve an important

purpose in ensuring ready communication among a

critical mass of investigators who share like interests,

a resource often not available to the behavioral

pe-diatrician at his or her own academic base.

2. Promotion of collaborative and interdisciplinary research that is integrative rather than corn partmental-ized. Evaluation of the contribution of early

interven-tion programs to child and family development is an

example of integrative research whereas a study of

the compliance of adolescents with a diabetic regimen as part of a diabetes training center grant represents

a largely compartmentalized investigation. Shared

re-search need not pose a problem in terms of promotion and tenure if the researcher demonstrates

independ-ent achievement by working on the answer to his or

her own question as a defined piece of the project.

The lack of funding for interdisciplinary research

from most granting agencies is, however, a constraint.

The reluctance of some disciplinary journals to

pub-lish interdisciplinary research should be addressed

not by new publications but by influencing the

pres-ent pediatric journals to increase the number of inter-disciplinary papers published.

3. Development of longitudinal and multisite investi-gations to provide more useful data in many behavioral pediatrics research areas (eg, the contribution of early intervention programs) by increasing the number of sub-jects available and comparison of intervention methods,

allowing sufficient time to document outcomes.

Al-though cohort studies of children are expensive, they

have been extraordinarily rewarding in answering

TABLE 2. Future initiatives for Behavioral Pediatrics

I. Establishment of research networks or consortia

2. Promotion of collaborative and interdisciplinary research 3. Development of longitudinal and multisite investigations 4. Multidisciplinary summer workshops for beginning and

mid-career investigators

5. Recruitment of outstanding behavioral pediatrics fellows 6. Establishment of national behavioral pediatrics resource library 7. Establishment of national centers of excellence in pediatric

biobehavioral and developmental research

8. Availability of stipends for research training in behavioral pediatrics

9. Appointment of an expert consensus committee for establish-ing research priorities

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832 FUTURE RESEARCH

fundamental questions regarding child development and behavior.

A community laboratory-a ‘behavioral’ Framing-ham project-would permit a large-scale, longitudi-nal, multidisciplinary approach to the identification of proximal risk and protective factors. The identifi-cation of both pediatric risk factors and the invulner-able characteristics that constitute resiliency would create the opportunity for testable interventions.

Although experience with interventions for adult

health behavior and lifestyle changes provides a

model for the administration, implementation, and evaluation of large-scale intervention projects, it pro-vides little information about the best targets for change in children. Once risk or protective factors have been identified, planning for intervention stud-ies requires a program to design and evaluate the most effective educational, motivational, and com-munity empowerment strategies. Studies to identify risk and protective factors must be longitudinal; in-volve large samples of representative populations; establish base rates of diseases and disorders; and use exemplary measures that capture proximal and distal health behaviors, morbidity, mortality, and social/ environmental factors.

4. Availability of multidisciplinary summer work-shops, like the Gordon or the Cold Spring Harbor pro-grams for the biological sciences, for beginning and mid-career behavioral pediatrics investigators. Such work-shops could focus on a range of topics (eg, assessment issues, research design, outcome measures, concep-tual issues, and data analysis). These sessions would

permit awareness of recent advances, sharing of

methodologies, development of new relationships,

and a more informed perspective on one’s own

re-search.

5. Development of a national initiative to interest talented medical students, especially those with a corn-bined MD/PhD degree, and pediatric residents in behav-ioral pediatrics research. Fellows in behavioral pediat-rics also need personalized guidance concerning their research careers. Discussion among the workshop participants brought forth the following recommen-dations for beginning behavioral pediatric investiga-tors:

a. Develop a focus and learn a particular subset of the

f

ield thoroughly. This recommendation centers on the importance of becoming an expert in a specific area of investigation. While a broad knowledge of behavior and development is desirable, and may contribute to creative ideas for research, a thorough

understanding of a defined area of study is a

prerequisite for scientific success.

b. Develop a detailed knowledge of funding sources for behavioral pediatric research. The importance of a broad familiarity with sources of research funding is particularly desirable given the relative paucity of agencies and foundations providing support for this area of investigation. Familiarity with both public and private sources of support, tenacity,

and the willingness and commitment to submit a

proposal repeatedly until the project is funded are key elements of success.

c. Select and persist with an important and researchable problem without allowing one’s personal research in-terests to be altered by shifts in funding directions.

While it is helpful to be ‘creatively adaptive’ in seeking research funding (ie, the young investiga-tor should learn the art of adapting a research idea to a specific request for proposals), it is critically important that the investigator maintain a commit-ted allegiance to the ideas that stimulated his or her original interest in research.

d. Identify and work closely with a senior mentor. A crucial aspect of an early research career is an alliance and collaboration with a mentor, either a single, senior investigator or a group of people engaged in similar work. The provision of guid-ance, nurturance, and blocks of protected time to pursue research are critical to academic develop-ment.

e. Read and collaborate across disciplinary boundaries.

Interdisciplinary study has a heuristic role in the generation of fresh, promising research ideas. Two ways of ensuring cross-disciplinary thinking is to read literature from a variety of fields and to en-gage in active research with investigators from other disciplines.

6. Establishment of a national behavioral pediatrics resource library. This repository should provide ready access to assessment and outcome measures (a major constraint in behavioral pediatrics research), to non-invasive technology applicable to children, and to data sets. Grants should be made available for inves-tigators to conduct secondary analyses on those data

sets that address unanswered but important

ques-tions. In addition, workshops to provide training on all aspects of the available data sets would help potential investigators conduct their analyses.

Whereas in some instances, assessment and

out-come measures need to be developed de novo and

tailored to unique research questions, in other cases,

measures that have been studied extensively and

validated already exist. Because these span so many disciplines, a considerable search is required currently for their identification. Creating clearinghouses for potential investigators and providing user guides to data from the National Center for Health Statistics or the National Survey of Children would also foster secondary analyses of large national data sets.

7. Establishment of national interdisciplinary centers of excellence in biobehavioral and developmental re-search in departments of pediatrics with a concentration of scholars from several disciplines. Modeled after cen-ters for the study of cancer, diabetes, or hypertension, the research in such centers would involve multiple levels of investigation ranging from basic science to clinical and epidemiological studies. Collaboration among investigators with different perspectives and methodologies focused on the same issue (eg, pain, injuries, the impact of poverty on children, and

pre-vention of disease and dysfunction, among other

possible themes) would better inform researchable questions and creative methodologies. Such centers would enhance the development of new knowledge

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and promote research and training for behavioral pediatricians.

If a joint decision were made by the National

Institute of Child Health and Human Development

and the Bureau of Maternal and Child Health to

introduce this initiative, symbolically illustrated in the

Figure, a request for planning grant proposals could

be made to departments of pediatrics. Such programs

need not be housed geographically entirely within

such departments but would establish programmatic

linkages with other academic departments, schools,

and universities. Ten 1-year planning grants could be

awarded with technical assistance offered to develop

detailed grant proposals. The state of the field of

behavioral pediatrics is now such that as many as

three such centers could be launched initially, with

support for 5 years and eligibility for competitive renewal given continued satisfactory performance.

8. Stipends for research training in behavioral pediat-rics. Three-year fellowships in behavioral pediatrics

are currently offered in the 1 2 programs funded by

the Research and Training Branch of the Bureau of

Maternal and Child Health. The William T. Grant

Foundation Faculty Scholars Program in the Mental

Health of Children also offers competitive grants with 5 years of support to young investigators in pediatrics and the behavioral and social sciences. The Pediatric Scientist Training Program, sponsored by the

Asso-ciation of Medical School Pediatric Department

Chairmen, provides postresidency fellowship support

for 2 years of biomedical or behavioral/social science research training in a nationally recognized labora-tory. While the Pediatric Scientist Training Program is an important advance for pediatric basic science training, it would be helpful to have additional sup-port available from other funding sources for rigorous training of behavioral pediatrics clinical investigators.

9. Appointment of expert consensus groups to identify research priorities. The highest priority might be given

The components of behavioral pediat-rics research.

to research areas that have a solid information base

and appropriate methodology and, therefore, are

poised for a significant expansion of knowledge. The

next priority level could be assigned to research areas that have a small but important base of accumulated data but need specific types of studies to elevate the

field to a higher level. A lower priority would be

allotted to those research areas that, though

impor-tant, presently do not have a funding base and need

initial studies to develop technical procedures or new methodologies in order to advance.

Content areas identified by the workshop

partici-pants as particularly significant for the coming years include the following:

a. Vulnerability in childhood. From both sociocultural

and psychobiological perspectives, the concept of

vulnerability-or exaggerated susceptibility to en-vironmental influences-is projected to be a key

focus of future research. The complementary idea

of resilience, or relative invulnerability to environ-mental challenges, is similarly identified as a prom-ising topic.

b. Normative aspects of child behavior and development.

An understanding of normal events and processes has been relatively neglected in contrast to describ-ing and attempting to correct abnormalities in child

development. Added emphasis should be placed

on investigating the ordinary, prosaic categories of

childhood experience as a means of elucidating

behavioral/developmental problems and

develop-ing preventive strategies.

c. Links between biological and behavioral processes.

Developmental psychobiology must be an area of

crucial concern in the coming years. Recent ad-vances in molecular biology and the neurosciences

create new opportunities for understanding

fun-damental connections between human biology and

behavior. Particularly in behavioral pediatric

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interac-834 FUTURE RESEARCH

tive relationships among biological and psychoso-cia! factors in the genesis of childhood disease and dysfunction.

:io.

Faculty development and starter grants for pedi-atricfaculty in behavioral pediatrics and rnidcareer train-ing awards to permit an investigator to spend up to I year in one or more research centers or to obtain training in another discipline. Full or minisabbaticals would

allow an investigator to spend time gaining new

research knowledge and skills from investigators in

another laboratory. Visiting professor programs

would also facilitate transmission of information,

technology, and research design.

THE CHALLENGE

This is an opportune time for behavioral

pediatri-cians. With 20% to 23% of the nation’s infants,

chil-dren, and adolescents demonstrating developmental,

behavioral, or learning problems, a plethora of

im-portant research questions await exploration. Such

research is eminently justifiable given such

funda-mental national problems as child abuse, hyperactiv-ity, learning problems, substance abuse, injuries,

risk-taking behaviors, acquired immunodeficiency

syn-drome, smoking, obesity, suboptimal nutrition,

ado-lescent pregnancy, pain, school dropouts, failure to

achieve one’s potential, and lack of physical fitness.

The number of menu choices for behavioral

pedi-atrics research is staggering, yet there is a serious

shortage of talented and trained pediatric

investiga-tors. Although this problem has no single or simple

solution, a number of strategies warrant thoughtful consideration.

Those suggested in this workshop include (1) the

establishment of networks or consortia for behavioral pediatrics investigators; (2) the promotion of collab-orative and interdisciplinary research; (3) the

devel-opment of longitudinal and multisite research

proj-ects; (4) the availability of multidisciplinary work-shops; (5) additional recruitment of pediatric residents into behavioral pediatric fellowships; (6)

establish-ment of a national behavioral pediatrics resource

li-brary; (7) funding of national interdisciplinary centers

of excellence in biobehavioral and developmental

research in departments of pediatrics; (8) availability of stipends for research training in behavioral pedi-atrics; (9) identification by expert consensus groups of research priorities and topics for funding and (10)

faculty development, starter grants, and midcareer

training awards for pediatric faculty in behavioral pediatrics.

Thus, there is much that should and can be done.

The challenge is to take the next giant step into the

future.

REFERENCE

1. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Pediatrics and the psychosocial aspects of child and family health. Pediatrics. 1982;70:126-127

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1992;90;830

Pediatrics

Zuckerman

Morris Green, W. Thomas Boyce, Jack W. Finney, Sheridan Phillips and Barry S.