This study reveals the referral trends of the DBP sub-specialty, which provides training, research, and service within one of Turkey's largest and best-equipped academic institutions. Furthermore, the study had to include the COVID-19 pandemic periods to evaluate the possible effects of the pandemic on developmental and behavioral issues, particularly in developing countries.
DBP training and services persisted in a few centers, one of which was an academic facility, throughout the period when referrals to HUDPD were examined between 2014 and 2021. In Turkey, a similar two-center study reported an annual 1.18-fold increase (95% CI: 1.09–1.28) in DBP referrals between 2010 and 2017 . Even though it was established as the third DBP center in the years that followed, annual referrals to HUDPD increased by 1.040-fold (95% CI: 1.015–1.067), indicating a significant expansion of division recognition and workforce. Additionally, given that the number of referrals in longitudinal studies evaluating the DBP workforce trend in HICs has mostly remained constant in recent years, it’s clear that the demand for DBP training programs, research, and services continues to grow in countries where DBP was recently established [7, 8].
The general pediatric outpatient clinic, which requests the most referrals from our division, has shown a significant increase in annual referrals. In a comprehensive study conducted in the United States of America (USA), pediatric generalists were responsible for the majority of referrals to the DBP for both time points . This improvement in awareness is quite encouraging, given the critical requirement of a developmental perspective in pediatrics and the lack of knowledge of pediatric residents on psychological and developmental issues [4, 15, 16]. We believe that time and rotation training was the most effective factors in this trend in referrals. As a result, the establishment of DBPs in developing countries, the increase in the number of training and service institutions, and subsequently, the support and collaboration of DBP specialists with young pediatricians throughout their residency training in chronic/inpatient follow-ups, as well as DBP rotations, allows them to improve their necessary knowledge and skills about developmental issues before serving in primary care .
The neonatology department was one of the most frequent referral sources, with perinatal risks remaining a common reason for referral and this findings were consistent with other studies in Turkey . In HICs, the number of neonatal follow-up referrals is relatively low . This condition in developing countries is likely to be attributed to an increase in risky babies caused by the inability to entirely remove maternal social, environmental, and biologic risk factors, as well as improved neonatal survival and a lack of health services in rural regions [18, 19]. There is a definite need for policies that will improve mother and newborn health as well as health services. The most common reasons for referral, after perinatal issues, were children with speech delays and developmental delay risk. A longitudinal study of pediatricians' developmental screening and referral trends in the USA reported that most referrals to a developmental or medical specialist were due to developmental delays in milestones and global developmental delays .
Neurologists, child psychiatrists and DBP professionals frequently collaborate in the care of children with behavioral, developmental, and learning difficulties, which have become much more common worldwide . The multidisciplinary nature of DBP education and practice is essential. Unfortunately, since the establishment of DBP, specialists working in this discipline have remarked that they face competition with other pediatric subspecialists and practice constraints due to a lack of clinical support from other professionals [5, 7, 8]. According to research, pediatric subspecialists screen and refer children and their families for psychological concerns at an extremely low rate . However, it’s well-known that the majority of children followed in these subspecialties have chronic medical conditions and are at high risk for developmental and behavioral problems, and family-level psychosocial stressors . Most pediatric subspecialties, as well as child and adolescent psychiatry, had referral rates of less than 5% in this study. It’s well-known that collaboration practices between various disciplines and professions are linked with improved health outcomes, accordingly, we need appropriate strategies to reduce potential competition, recognize DBP's education, service, advocacy, and research roles in pediatrics, and ensure effective collaborations . Given that the majority of DBP specialists in countries where the division was newly established are university-based, improved awareness and collaboration of other pediatric subspecialties in these institutions will eventually have a positive influence on primary care services.
The policies associated with the global COVID-19 pandemic caused negative factors at the level of children, families, and services, led to physical, mental, and developmental issues in children, increased parental anxieties and household stress, and restricted access to healthcare . The pandemic has resulted in a decline in vaccine orders and vaccination admissions, according to reports from the Centers for Disease Control and Prevention (CDC) . Diminished vaccine administrations and, interruptions in well-child follow-up could preclude the diagnosis of developmental delays and referral to early intervention programs for children, who are the most vulnerable to the pandemic's devastating effects . These potential morbidities in children are likely to occur more frequently in developing countries, where healthcare restrictions and economic challenges are more severe. In this study, there was a significant decrease in the number of referrals after March 2020; however, by October 2021, the number of referrals had recovered to its prior trend. This demonstrates that the pandemic's detrimental effects on access to healthcare are being mitigated. Furthermore, as compared with the pre-pandemic period, the increase in referrals due to perinatal risk was a remarkable finding in our research. As shown by studies, pregnant women are minimizing their pregnancy follow-up checkups because of concerns about the danger of COVID-19 infection , and they are feeling significant psychological symptoms, particularly depression and anxiety symptoms, as a result of pandemic-related conditions . Additionally, access to healthcare may have negatively affected maternal, fetal, and neonatal health [12, 26], increasing the number of risky babies and the requirement for follow-up.
Identifying Autism Spectrum Disorder (ASD), an increasingly prevalent disorder worldwide, and enrolling children in early intervention services improves outcomes and reduces long-term costs for families and governments . Even though the necessity of face-to-face field evaluations in the autism diagnostic process is well known, the barriers and solutions in autism examinations during the outbreak are being challenged all over the world . Clinic access for children with suspected or diagnosed autism may be further prolonged in developimg countries where healthcare interruptions and social inequalities are more severe and telehealth services cannot be structured. The accumulation of children who cannot receive health services due to these disadvantages may be the cause of the 1.209-fold increase in referrals requested from HUDPD with the suspicion of autism after the pandemic. Children have lost opportunities for social interaction with their peers during the pandemic, and their social skills have regressed. Parent-child interactions were also damaged by the chaotic home environment caused by school closures, parental jobs lost, economic challenges, or the requirement of working from home . Furthermore, during the pandemic, children's screen time has increased . Significant longitudinal research has indicated that long screen time is associated with ASD and autism-like symptoms . All of these potential consequences could have resulted in an increase in DBP referrals for suspected autism. The potential impact of the COVID-19 outbreak on the prevalence of autism, a current health issue, will take time to determine, and our study's findings draw attention to this topic.
One of the study's strengths is that HUDPD is one of the three major academic institutions providing residency training and family-centered services in the field of DBP in Turkey and it analyses patient referrals over an 8-year period. The changes in the numbers and reasons for referrals, as well as the departments that request them, over time, indicate that developing strategies and collaborations for both our department and countries where DBP will be re-established is recommended. Another strength of our study is that it is the first to evaluate DBP referrals during the COVID-19 pandemic, and demonstrating the pandemic's potential deleterious impacts on early childhood, including at-risk children. The aspect that it was a single-center study can be considered a limitation, despite the fact that it was conducted in one of the rare and comprehensive academic centers where a DBP clinic is located.