The New CDC Milestones Effect on Early Intervention

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For the first time in 20 years, the CDC updated their developmental milestones for speech and language despite contradictions to the American Speech/Language Hearing Association’s well-researched milestones. Some sources claim The CDC milestone changes have nothing to do with the effect of the COVID-19 on speech and language development. In short, they explained it was a long time coming.

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Why?

The rationale is that they have changed the percentages at which 75% or more of children can be expected to exhibit certain behaviors based on data, developmental resources, and clinical expertise. For example, “If you share the concern that your child isn’t walking at 18 months when 75% of kids would be expected to, it is more indicative of a possible concern that warrants action. In summary, a missed milestone expected of 75% or more of children is more clearly actionable than a missed milestone expected of only half of children that age.” [2].

While the CDC presents this information in a way that seems as though it will help to ID more children with speech/language concerns, the language and communication milestone revisions have many SLPs and parents concerned. The CDC has pushed back language milestones to later ages after conducting research that began before the pandemic. At this point, about 80% of the milestones are evidence-based, and about 20% are based on clinical judgment. [1]

“The result is that while parents of a 12-month-old previously would have been told their child should be starting to talk, the guidelines say that behavior is now expected of babies at 15 months. Because that’s when research shows at least 75% of children are doing so. Similarly, the milestone for walking moved from 12 to 18 months.” [2]

The CDC has claimed that the updated milestones are supposed to help with the early identification of ASD and other social communication disorders. So we know why they were changed, but are left wondering… how?

It’s time for some….

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Put on your imagination cap and picture these 3 scenarios:

1. You are a parent of a one year old child who hasn’t said their first word yet. After looking up speech/language milestones from the CDC, you worry about your child’s speech and language development. All research points to the earlier the better in regard to speech therapy, so you seek professional help from a speech-language pathologist and enroll your child in an early intervention program. You are informed that early intervention services are provided from birth to three. Your team works together to form an individualized family service plan (IFSP) to carry out for the next two years prior to preschool. After working with an SLP, your child says their first word, then another, then another, until they reached their vocabulary burst. Your child is now on track for speech and language development before enrolling in preschool.

2. You are a parent of a one year old child who hasn’t said their first word yet. You worry about your child’s speech and language development, but you notice the CDC milestones report that your child may not acquire their first word until 15 months. So you take the “wait and see” approach. By 15 months, your child is still not saying any words. You’ve read that there is a huge range of typical development and assume that they still have time to develop. At 2 years old your child only has one or two words, so you seek professional help from an SLP. At this point, you enroll in an early intervention program, with an IFSP. The SLP informs you that early intervention services are only provided from birth to three. At that point, you realize you only have one year of early intervention services. Because you’ve taken the wait-and-see approach, when your child enrolls in preschool, their communication skills are far less advanced than age-matched peers.

3. You are a parent of a one year old child who hasn’t said their first word yet. You have additional concerns like lack of communicative intent, solitary play, repetitive/restrictive behaviors, and a general disinterest in interacting with others. You worry about your child’s speech and language development as well as their use of social language. You notice the new CDC guidelines report your child may not acquire their first word until 15 months. However, your intuition tells you something more is going on. So you seek professional help from a speech-language pathologist. The SLP agrees that your child should enroll in an early intervention program. You contact insurance who refuses to cover the cost of therapy because your child’s milestones are still within normal limits according to the CDC. Because you missed the critical window for early identification, when your child enrolls in preschool, their communication and play skills are underdeveloped when compared to their peers. Soon after starting preschool, your child’s teacher contacts you with a concern about possible Autism Spectrum Disorder. Now you’ve missed the critical window to optimize treatment outcomes through early intervention and your child is now falling behind in school before it even started. [4]

These examples are not to say therapy will not be affective if started around 2 years old. But time and time again, research shows that early intervention optimizes treatment outcomes. When it comes to speech therapy, earlier intervention is always better than the wait and see approach. Many SLPs worry that these new milestones will limit services to early intervention.

SLP Concerns

On that note, when the new milestones were posted there was a lot of pushback from SLPs. Some of their top concerns are listed below [5]:

  • “The criteria and milestones added for the 15- and 30-month health supervision visits result in a 26.4% reduction and 40.9% replacement of previous CDC milestones.
  • A third of the retained milestones are transferred to different ages; 67.7% of those transferred are for older ages.
  • Approximately 80% of the final milestones have normative data from one or no source.
  • Gaps are evident in the data for social-emotional and cognitive milestones, which also have the least normative data.
  • While the CDC/AAP information can be used to support developmental surveillance, it ought not to be used to make clinical decisions.” [5]

ASHA Statement

On February 21, 2022, the American Speech, Language, and Hearing Association made a statement regarding the new CDC milestones, “ASHA is in the process of analyzing the recent revisions to the developmental milestones used in the Centers for Disease Control and Prevention (CDC) “Learn the Signs. Act Early” initiative. This process includes a comprehensive comparison of the previous vs. new guidelines, as well as a comparison to ASHA-specified milestones. ASHA is also conducting an extensive review of published scientific literature.”

“ASHA has reached out to CDC, expressing its concern about inconsistencies and urging the agency to utilize the expertise of SLPs when making changes to developmental milestones in speech, language, feeding, and social communication. In general, ASHA is supportive of efforts to help identify children earlier, but the milestones presented to parents must be evidence-based in order for families to make well-informed decisions about their children’s care.” [3]

CDC and AAP Points from Conversation with ASHA

“The groups also specified that the revised milestones are [5]:

  • Evidence-informed, not expert-developed.
  • More clearly actionable to boost developmental screening and referral.
  • A communication tool, not a screener
  • Not developmental screening tools, nor are they standards or guidelines. Thus, they do not lower standards of early childhood language development.
  • Shouldn’t affect how or if children are evaluated or qualify for services.

In summary, ASHA pointed out that these “checklists and milestones” are problematic for the qualification of services despite the CDC’s intentions. Furthermore, they are not inclusive of multilingual and neurodivergent children who may acquire language differently. In addition, they reminded parents and clinicians that ASHA is the go-to source for speech and language milestones because the CDC guidelines are misleading.

Resources for Parents

For parents left wondering what all of this means for their child, ASHA gave a helpful statement regarding the CDC milestone changes:

“ASHA understands that families want clear information. Milestones provide guidance about the development and sequences of skills. Every child develops at their own rate. This is why the milestones on ASHA’s website are presented as a range. Again, ASHA encourages parents/caregivers to trust their instincts and seek an evaluation (these evaluations are available for free through public early intervention programs) if they have concerns. A physician’s referral is not needed: Families can directly contact their local agency (see this list by state) or their neighborhood school to be connected with help (even if their child is not yet enrolled in school).” [5]

References:

  1. The CDC and AAP are adjusting the milestone benchmark to easily track development for babies 
  2. PolitiFact | What to know about the CDC’s updated developmental milestones for infants and young children
  3. ASHA Statement on CDC’s Updated Developmental Milestones  
  4. New Developmental Milestones: Reviewing the Changes and Evidence 
  5. CDC Milestones Are Intended as Tool, Not Screening, Agency Officials Clarify
  6. Frequently Asked Questions: CDC and AAP Developmental Milestones Updates

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