Developmental Pediatrics Research Articles

Risk stratification helps identify congenital diaphragmatic hernia (CDH) infants in need of formal neurodevelopmental assessment: Observations from a structured, interdisciplinary long-term follow-up clinic

Background/Purpose: Neurodevelopmental delay (NDD) affects congenital diaphragmatic hernia (CDH) infants. Initial assessment by experienced developmental pediatricians, supported by Bayley-3 tests, is a viable pathway for NDD identification and surveillance. We risk stratified CDH infants to observe differences in incidence and type of NDD based on disease severity. Methods: Patients from a CDH long-term follow-up database started in 2012 were reviewed (REB#2019–4583). Risk stratification into low, moderate, and high-risk cohorts was performed using the CDH Study Group Mortality Prediction Score. Patients requiring ECLS, supplemental oxygen at 30 days and patch repair were also considered high-risk (i.e. usual clinical criteria). Post-discharge NDD assessments by developmental pediatricians and occupational therapists (Bayley-3) were analyzed for all patients >18months. NDD incidence and type per risk group was determined using descriptive statistics. Results: Of 102 CDH patients included for study, 26% (27/102) had NDD. Risk stratification identified 2(2%), 7(7%), and 18(18%) patients with NDD in the low, moderate and high-risk groups, respectively. Language delay (2 low; 6 moderate; 10 high) was the most prevalent. Three patients had both expressive and receptive language delay. Motor deficits were observed almost exclusively in the high-risk group. Conclusion: Based on our experience, NDD affects one-quarter of CDH infants. Risk stratification helped identify infants at increased risk of NDD. While language delays predominated across all risk groups, multiple deficits occurred in higher risk cohorts. These patients should receive structured NDD assessment as part of an optimal interdisciplinary CDH care pathway.

Prevalence of minor physical anomalies in children with autism spectrum disorder reporting to a tertiary care hospital Lahore-Pakistan.

Objective:To assess the frequency and type of minor physical anomalies (MPAs) in subjects with autism spectrum disorder (ASD).Methods:This descriptive cross-sectional study was conducted from September, 2016 to October, 2020. Using purposive sampling technique, 147 subjects with ASD were recruited from Children’s Hospital and Institute of Child Health (CH & ICH) Lahore, with a confirmed clinical diagnosis by developmental pediatrician, using Diagnostic and Statistical Manual of Mental Disorders (DSM-V). For morphology assessment, 12 body regions of ASD subjects were examined using Autism Dysmorphology Measure (ADM) manual after taking informed consent. Physical measurements (height, weight, head circumference, ear length, philtrum, hand, finger and foot length) were also taken and were compared with the available standard charts.Results:A total of 381 dysmorphologies were identified in 131 (89.1%) ASD subjects whereas 16 subjects had no dysmorphology at all. Microcephaly was exhibited by 14 (9.5%) subjects, out of which 13 had variable number of dysmorphologies while one had no dysmorphology in other body regions. Out of 131 subjects exhibiting dysmorphologies, there were 108 male and 23 female subjects, with a M:F ratio 4.7:1 whereas microcephaly was observed in 12 male and two female subjects, with a M:F ratio 6:1. The highest number of dysmorphic features were noted in the ears, followed by feet and hair growth pattern.Conclusions:MPAs associated with ASD are frequently found in, but are clearly not limited to, the head or facial region.

Fast Tracking Assessment of Attention Deficit Hyperactivity Disorder in Tertiary Care.

Current pediatric practice guidelines recommend children with complex attention deficit hyperactivity disorder (ADHD) receive a psychological evaluation. However, obtaining such an evaluation in a timely manner can be difficult. The authors present a framework for an economical, efficient, and efficacious approach to diagnosing complex ADHD based on a 5-year project to “fast track” these types of assessments in a tertiary care setting. Patients were triaged to the “fast track” for a streamlined assessment, by a psychologist, within a developmental pediatrics center. Assessment data, diagnoses, and recommendations were recorded for 79 participants. For most of the children, not only was ADHD confirmed, but diagnostic criteria were also met for at least one comorbid condition. For 64% of children the diagnostic picture changed, resulting in an ADHD diagnosis with corresponding changes to treatment planning. Fast track programming cut the wait time for evaluations in half. Preliminary data shows it is possible to clarify diagnoses for this complex population and provide much needed treatment recommendations in a timelier manner through utilization of a “fast track” approach to triage and assessment.

Adults with Neurodevelopmental Disorders Continue to Receive Lower Quality Health Services: A Call for "Quality Improvement" Programs

Neurodevelopmental Disorders (also known as Intellectual and Developmental Disabilities-ID/DD) are associated with multiple-complex-health-conditions that, in contrast to children, are often not evaluated and/or managed properly as adults. The specialty of Developmental and Behavioral Pediatrics exists for children with ID/DD, but there is no equivalent specialty for the adults.

Early language development in children with autism (ages 3 - 5 years) in Bloemfontein, South Africa: A comparative study

Background. Autism is a developmental disorder, which presents during the childhood years, with social communication difficulties and signs of delay in early language development. Objectives. The aim of the study was to compare the early language development of children aged 3 - 5 years with a Diagnostic and Statistical Manual of Mental Disorders (DSM) V diagnosis of autism with that of children of the same age with typical early language development. The secondary aim was to determine if certain children with autism have better language development in the language to which they are exposed on television (English) than in their home language (Afrikaans). Methods. The Language Development Survey was translated into Afrikaans, modified and used as a questionnaire. For the control group, questionnaires were distributed at preschools and completed by the parents. For the sample group, questionnaires were distributed at the practice of a developmental paediatrician. Results. The median percentages of Afrikaans words used in all the categories were lower in the sample group than in the control group. More children in the sample group tended to speak English the best, use words not spoken at home, and imitate words and sounds in the incorrect context. Most of the parents of children in the sample group considered their child’s language development poor. Children in both groups watched television for long periods of time. Conclusions. Afrikaans-speaking children with autism have a poorer vocabulary in Afrikaans and used more English words than in the control group. The television exposure of children under the age of two years is high.

The impact of birthweight on the development of cerebral palsy: A population-based matched case-control study

BackgroundCerebral palsy (CP) is a common cause of physical impairment in children, especially in newborns who are small for gestational age (SGA). AimsThe aim of our study was to investigate the association between birth weight and the risk of developing CP, controlling for gestational age and plurality. Study designThis retrospective, observational, case-control study was based on Slovenian Registry of Cerebral Palsy (SRCP) and Slovenian National Perinatal Information System (NPIS) data for the period 2002 to 2010. SubjectsFor each pregnancy that resulted in the birth of the newborn(s) who later developed CP (n = 254), three pregnancies with newborns who did not develop CP (n = 762) were selected and matched for gestational age and plurality. Outcome measuresDiagnosis of CP was made at age 5 years or older by a developmental pediatrician trained in child neurology or a child neurologist using standard measures. ResultsRisk of CP increased progressively as birth weight percentiles fell below the 50th centile, with children in the lowest percentiles at greatest risk. Birth weight percentiles traditionally classified as SGA were an independent risk factor for developing CP, with an odds ratio of 2.43 (95% confidence interval 1.57, 3.73). ConclusionsThe results of this study suggest that the risk for developing CP is inversely related to birth weight, even at birth weights that do not meet the standard definitions of SGA. Synopsis - study questionDoes birth weight represent a potential risk factor for the development of cerebral palsy (CP) when controlling for gestational age and plurality? What's already knownNewborns who are small for gestational age (SGA) are at higher risk of developing CP according to published studies. However, different definitions of SGA (birth weight below the 10th, 5th, or 3rd percentile for gestational age) have been used by researchers and clinicians, making it difficult to compare studies. What this study addsThis study suggests that the risk of developing CP is inversely related to birth weight, even at birth weights that do not meet standard definitions of SGA.

Who is managing the bowels? A survey of clinical practice patterns in spina bifida clinics.

Neurogenic bowel dysfunction (NBD) affects 80% of individuals with spina bifida. Performing and disseminating research on NBD to reach the appropriate audience is difficult given the variability among medical specialties managing NBD. This study aimed to identify which medical specialties and types of providers are currently managing NBD in the United States. A survey was developed and sent to 75 spina bifida clinics. Surveys queried which specialty was primarily responsible for medical and surgical management of NBD and any others that assist in NBD care. The license and certification level of the providers were collected. Descriptive statistics were performed to describe the results. Response rate was 68%. Urology was the leading specialty primarily responsible for NBD management (39%) followed by rehabilitation medicine and developmental pediatrics (22% and 20%, respectively). Physicians were the primary providers of care followed by nurse practitioners (54% vs 31%). Urology performs 65% of NBD surgeries. Multiple specialties and providers are involved in NBD management with variation among clinics. Development of improved NBD care should include a spectrum of specialties and providers. Dissemination of research should be aimed at multiple specialty groups.

7P pediatrics — Medicine of Development and Health Programming

The transition to personalized, predictive, preventive and participatory medicine, due, among other things, to the achievements of fundamental science, digitalization and the development of information and communication technologies, naturally demanded changes in childrens health care. New organizational, methodological and technological changes that have taken place to ensure a highly dynamic, adapted, and, at the same time, permanent provision of the medical process anywhere and at any time, have led to the need for specialists of a new formation a pluriexpert team ready to work in new conditions: how to participate in research in fundamental science, and to the introduction of innovative methods in clinical practice, medical and social support and the educational process. In these conditions, the strategic goal set for pediatrics to analyze absolutely all aspects of health: somatic, neuropsychic, emotional and psycho-social, in the process of growth and development of a child from conception/birth to adolescence / adulthood was implemented in a new direction of clinical and fundamental medicine developmental pediatrics and child health programming. 7P-pediatrics: Programming the development and health of the child, Preventive, Predictive, Personalized, Participatory, Polyprofessional (Pluriexpert), Progressive medicine for children, in which the results of scientific work based on fundamental data and ideas of neurosciences about progressive development and modern methodology of educational support of the entire medical process are fully translated into a clinical practice.

Teleconsultation during a pandemic. Experience of developmental pediatricians at Hospital de Pediatría "Prof. Dr. Juan P. Garrahan".

Teleconsultation is one of the components of telemedicine. Developmental pediatricians provide assessments and followup to children with developmental challenges. During the pandemic, due to movement and travel restrictions and the importance of continued care, pediatricians started working remotely with virtual consultations. The objective of this study was to describe the implementation of virtual care, the characteristics of patients seen, and their families' perception. A total of 122 teleconsultations were scheduled. Patients' mean age was 40 ± 13 months. The most common reasons for consultation were absence of and delay in language and behavioral difficulties. Although 16 % of families described some obstacles, all were grateful for the consultations. Virtual health care should be regarded as a complement to in-person care, alongside reductions in costs and travel time and the possibility.

Fever and Abdominal Pain in a 10-year-old with Autism.

Fever and Abdominal Pain in a 10-year-old with Autism.

Society for Developmental & Behavioral Pediatrics Position Statement on Telehealth.

Telehealth has long held promise as a way to increase access to subspecialty care for children and families, including in developmental and behavioral pediatrics (DBP). The coronavirus disease 2019 (COVID-19) pandemic necessitated rapid uptake of telehealth to continue care delivery that was facilitated by "temporary" policy changes related to the pandemic. As a result, the field of DBP has recognized telehealth as a potential model of care for performing home-based diagnostic assessments, providing medication management follow-up, and delivering therapeutic interventions for children with neurodevelopmental disorders. Telehealth has been helpful in mitigating barriers families often face when attending in-person visits (lack of transportation and child care, missed work hours, etc) but has also highlighted additional determinants of health that need to be addressed to provide equitable access to care (broadband connectivity, device access, digital literacy, access to interpretation and sign language services, etc). Anticipating the lifting of pandemic-related emergency declaration and expiration of temporary policies around telehealth, the ability to continue to deliver DBP care by telehealth is uncertain. The purpose of this policy statement is to advocate for legislation and policies that support ongoing, equitable, home-based telehealth care for patients seen by DBP providers while ensuring equitable access to DBP in general. In addition, there is a need to recognize the benefits and challenges of telehealth versus in-person care and to identify clinical scenarios that favor 1 model of care versus the other.

Utilization of psychotropic medications in children with FASD: a retrospective review

BackgroundFetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental condition resulting from pre-natal alcohol exposure. In Canada, an estimated 1.4-4% of newborns are affected by FASD. FASD is often associated with behavioural comorbidities and many individuals require psychotropic medication. However, to date there are no FASD specific guidelines for prescribing medication. Recently, Mela and colleagues described four behavioural symptom clusters commonly seen in FASD with suggested pharmacologic treatment for each cluster within an algorithm. The primary objective was to compare the proposed treatment algorithm retrospectively to actual treatment in a real-world FASD pediatric practice. The secondary objective was to refine the description of symptom clusters which will be targeted with treatment.MethodsWe collected the diagnostic and medication history from all patient visits of a Regina Developmental Pediatrician who specializes in FASD diagnosis and medication treatment. Three hundred fifty-four FASD patients were identified between 2005 to 2020. The medications that would be predicted from the algorithm were compared to the real-world historical data. A positive case was defined as all algorithm-predicted medications matching the historical data; a negative case had one or more medications failing to match.ResultsOf the 354 patients, 36 were removed for insufficient information. Of the remaining 318 cases, 172 (54.1%) were positive compared to 146 (45.9%) negatives. In single prescription cases (n=147), the incidence of positives was 67.3%; in multi-prescriptions (n=72) it was 27.8%; and in cases where no prescription was needed (n=99), the positive incidence was 53.5%.ConclusionsThe prescription algorithm is promising but requires further refinement to accommodate the range of presentations in children with FASD. With respect to unclassified symptoms, we propose the following: sleep onset difficulty as hyperarousal; gender dysphoria and obsessive compulsive disorder as cognitive inflexibility; grief as emotional regulation; and autism spectrum disorder as hyperactive/neurocognitive.

Interpretation of American Society for Developmental and Behavioral Pediatrics clinical practice guideline for the assessment and treatment of children and adolescents with complex attention-deficit/hyperactivity disorder

注意缺陷多动障碍是儿童期最常见的神经发育障碍，可导致多种功能损伤并增加成年期精神与心理健康风险。2020年美国发育行为儿科学会发表了“儿童及青少年复杂注意缺陷多动障碍评估和治疗的临床实践指南”，首次提出“复杂注意缺陷多动障碍”的定义，并提供了详细的综合性、跨专业的评估及治疗方案。本文就该指南进行解读，以期为评估、治疗及管理复杂注意缺陷多动障碍儿童及青少年提供相关帮助。.

The involvement of community pediatricians in the treatment of developmental-behavioral difficulties as perceived by directors of child development centers

BackgroundDevelopmental-behavioral issues are among the most frequent and disabling conditions of children and adolescents seen in ambulatory settings. Guidelines of the Israeli Pediatric Association and the Israeli Society for Developmental Pediatrics specify the role of the primary-care pediatrician in screening and early identification of mild developmental behavioral conditions and define the criteria for referral to child development institutes. The aims of this study were to examine and describe how directors of these institutes perceive the role and involvement of community pediatricians in child development.MethodsQualitative interviews of the directors of 22 child development institutes from the ministry of health and the four health plans.ResultsAccording to the interviewees, there is little involvement of community pediatricians in detecting developmental delays, and it is mainly nurses and preschool teachers who detect such delays. They report that the key barriers that deter community pediatricians from greater involvement in child development diagnosis and treatment are lack of time, lack of compensation, and insufficient clinical knowledge. The interviewees would like to see community pediatricians conducting the primary medical evaluation, providing parental guidance, referring to therapists in mild cases, exercising discretion before referring children to child development institutes and providing relevant information to the institutes in the referral process. The mechanisms that they proposed for increasing the involvement of community pediatricians were expansion of pediatricians’ training, increased pediatricians’ use of teleconsultation with child development specialists and incentives for thorough performance of developmental assessments.ConclusionsDue to the importance of the Issue, we strongly recommend that policymakers require child development principles, evaluation, and providing appropriate parental guidance in the curriculum of the Israeli pediatric residency program. In addition, health plans should compensate pediatricians who need to conduct longer visits for children with developmental delays. The health plans should also develop teleconsultation channels for pediatricians with child development specialists to reduce unnecessary referrals to child development institutes.

Developmental Behavioral Pediatrician Perspectives on Decision-Making in Early Treatment Planning for Children with Autism Spectrum Disorder.

Providers of children with autism spectrum disorder (hereafter "autism") report higher levels of shared decision-making during initial diagnostic and treatment planning visits than observed. The goal of this study was to qualitatively explore this discrepancy by investigating provider perceptions of the parent-provider decision-making process in early treatment planning and the role for parents in this process. We conducted semistructured qualitative interviews with developmental behavioral pediatricians (DBPs; n = 15) to investigate how they approach early treatment planning with parents. We analyzed participant characteristics using descriptive statistics. Interviews were audio-recorded, transcribed, and independently coded by 2 researchers until consensus was reached. Analyses were conducted using a modified grounded theory framework. DBPs reported that their primary role during early treatment planning was to provide diagnostic clarification and that parents' primary role was to learn as much as they can about autism. Most DBPs wanted treatment planning to be collaborative, and perceived that parents had the same preference but might not have the knowledge or skills to effectively participate. DBPs identified additional barriers that influence the extent to which they engage parents in the collaborative decision-making and provided recommendations for enhancing the process. DBPs are proponents of collaborative treatment planning between parents and providers; however, there are many obstacles that prevent this. Strategies such as decision tools or aids and larger systemic reforms are necessary to support DBPs and parents in this process.

6.2 Evaluation of an Artificial Intelligence–Based Medical Device Designed to Aid in the Diagnosis of Autism Spectrum Disorder in the Primary Care Setting

The lack of diagnostic tools for autism spectrum disorder (ASD) in primary care settings and long waiting lists for specialist assessment contribute to an average delay of 3 years between first parental concern and diagnosis. This study examined the performance of an artificial intelligence–based device intended to aid primary care practitioners (PCPs) in the diagnosis of ASD. This was a prospective multisite pivotal study conducted in 6 states using a double-blind active comparator design with 425 completed subjects (36% female) ages 18 to 72 months with concern for developmental delay. Previous research developed, tuned, and tested a device that uses a gradient-boosted decision-tree machine learning algorithm that analyzes 64 behavioral features from 3 distinct inputs: 1) caregiver questionnaire; 2) 2 to 4 minutes of home videos analyzed by trained video analysts; and 3) PCP questionnaire. Device results were compared to diagnosis by independent agreement of specialist clinicians based on clinical assessment, including a modified Child Autism Rating Scale (CARS-2) and DSM-5 criteria. Specialists were child and adolescent psychiatrists, child psychologists, pediatric neurologists, and developmental behavioral pediatricians experienced in diagnosing ASD. Comparison of device results to specialist diagnosis found the following for subjects with determinate device results: positive predictive value (PPV) = 80.8% (95% CI, 70.3-88.8); negative predictive value (NPV) = 98.3% (90.6-100); sensitivity = 98.4% (91.6-100); and specificity = 78.9% (67.6-87.7). There was no evidence that device performance significantly varied when the PCP used the device remotely compared to in-person. Using this device, PCPs could efficiently, accurately, and equitably diagnose a subset of children aged 18 to 72 months old, thereby streamlining specialist referrals and facilitating earlier ASD diagnosis and interventions. The results further provide preliminary evidence that PCP evaluation of the child can be done via telemedicine or in-person with no degradation in device performance.

1.3 TRAINING AND SUPPORTING RURAL PEDIATRICIANS IN THE IDENTIFICATION AND CARE OF FAMILIES AFFECTED BY TRAUMA

Kennedy Krieger Institute’s Network for Early Childhood Tele-Education (KKI-NECT) is a case-based learning collaborative to address behavioral, emotional, and developmental concerns in children ages birth to 5 years. The speaker will give a brief overview of KKI-NECT and present findings from the Health Resources and Services Administration (HRSA)-funded program. KKI-NECT replicates the Project ECHOTM (Extension for Community Healthcare Outcomes) model of a “hub” (KKI developmental pediatricians, child and adolescent psychiatrist, and behavioral psychologist), which hosts weekly “clinics” (teleconferences) with “spokes” (10-12 pediatric primary care providers) in underserved areas across the states of Maryland and West Virginia. The frequency and types of traumatic experiences in the cases discussed during the sessions, as well as the methods to train and support primary care providers in identifying and addressing trauma in their patients, will be presented. Finally, a short case example will illustrate the nature and complexity of cases being managed rurally by nonspecialists, with the support of the KKI-NECT team. Over 4 years, 85 unique cases were presented by rural pediatric providers for assistance with diagnosis and management by specialists in the hub. Among these 85 unique cases, 69% of the cases presented had a least 1 adverse childhood experience (ACE) as compared to 45% of children in the United States. In addition, 37% had 3 or more ACEs, putting them at higher risk for poor outcomes, as compared with 10% nationally. The most common ACEs were parental separation, household substance use, and parental mental illness. Pediatricians are uniquely positioned to intervene because early childhood trauma is often undetected or unreported. Traumatic experiences have been described in the majority of cases discussed during the KKI-NECT clinics. KKI-NECT provides an opportunity for both education and support for pediatric providers as they respond to trauma-related concerns in their patients.

Assessing parental understanding of variant reclassification in pediatric neurology and developmental pediatrics clinics.

Improvements in technology used for genetic testing have yielded an increased numbers of variants that are identified, each with a potential to return uninformative results. While some genetics providers may expect patients to be responsible for staying abreast of updates to their genetic testing results, it is unknown whether patients are even aware of the possibility of variant reclassification. Little research has assessed the comprehension and attitudes of parents of pediatric patients regarding reclassification of variants of uncertain significance (VUS). Semi-structured telephone interviews were conducted with parents (n = 15) whose children received a VUS from genetic testing in either the pediatric neurogenetics or developmental pediatrics clinics at Riley Hospital for Children in Indianapolis, Indiana. Most participants expressed understanding of the uncertainty surrounding their child's VUS test result. However, nearly half of participants shared that they had no prior knowledge of its potential reclassification. When asked whose responsibility it is to keep informed about changes to their child's VUS status, some participants stated that it belonged solely to healthcare providers - a distinctive finding of our study - whereas others felt that it was a joint responsibility between providers and the parents. We additionally found that some patients desire a support group for individuals with VUS. These results provide insight into the importance of pretest genetic counseling and the need for increased social and informational support for parents of children who receive inconclusive genetic testing results. We conclude that relying solely on the patient or guardian to manage uncertain results may be insufficient.

Prevalence and Initial Diagnosis of Cerebral Palsy in Preterm and Term-Born Children in Taiwan: A Nationwide, Population-Based Cohort Study.

The aim of this long-term longitudinal study in Taiwan was to estimate and compare the prevalence of cerebral palsy (CP) and to identify the age of CP diagnosis of term-born and preterm children with different birthweights. Records of 1494 extremely low birth weight (ELBW, <1000 g), 3961 very low birth weight (VLBW, 1000–1499 g), 19,612 low birth weight (LBW, 1500–2499 g) preterm, and 100,268 matched term-born children were retrieved from Taiwan′s National Health Insurance Research Database. According to a 12-year retrospective data review, the results showed the highest prevalence of CP in preterm ELBW children (147.3 cases per 1000 neonatal survivors), followed by preterm VLBW (97.2 cases), preterm LBW (27.7 cases), with the lowest prevalence in term-born children (2.5 cases). Regardless of the birthweight group, 90% of preterm children with CP were diagnosed by 4 years of age, but it was 7 years before 90% of term-born children with CP were diagnosed. After removing the children whose CP was caused by brain infections, injuries, or cerebrovascular accidents after 4 months of age, there were similar mean ages at the initial CP diagnosis (1.58–1.64 years of age) across birthweight groups born prematurely, but initial diagnosis occurred at an older age (2.41 years of age) in term-born children. The results indicate that birthweight is reversely correlated with the prevalence of CP in preterm children. Although the three preterm birthweight groups received different types of developmental follow-up programs after birth, it did not influence their age at the initial diagnosis of CP. Furthermore, we suggest that follow-up for at least 4 years after birth for preterm children, and 7 years for term-born children, is optimal for estimating CP prevalence. In order to identify and provide early intervention for term-born children with CP earlier, it is suggested that parents routinely fill out a self-reported motor developmental screening questionnaire and pediatricians conduct a motor developmental examination on term-born children at each time of scheduled vaccination injections.

Developmental Disability: Families and Functioning in Child and Adolescence.

The WHO's International Classification of Functioning, Disability and Health (ICF) provides an integrated framework for health for everyone. Several aspects of this approach to health allow us to see people's lives in a richer and more holistic manner than has traditionally been the case based on diagnosis alone. These features include the positive language (emphasizing in particular “activity,” “participation,” and “personal factors”); the interconnections of the parts of this “dynamic system,” in which every component can influence every other one; and the formal inclusion of “contextual factors”—personal and environmental—that are otherwise too easy to take for granted and then ignore. This paper addresses the “environmental” dimension of the ICF framework—specifically referring to “family” as the central environmental force in the lives of children and adolescents. The perspectives of the author are those of a developmental pediatrician, whose career has focused on children with conditions that challenge their development, and their families. Lessons learned from a lifetime of work—including teaching and research as well as clinical services—are offered. Particular emphases will be on (i) the importance of focusing on the family in a non-judgmental “family-centered” way; (ii) how conceptual ideas about child (and family) development and parenting are as important as technical approaches to intervention; and (iii) how the ICF framework “allows”—indeed encourages—such a focus to have value and importance equal to the best of biomedical interventions. Examples from current research will illustrate how these ideas can be implemented.