Cue the controversy…
The official CDC guidelines for children’s developmental milestones1 were updated this month (February 2022) for the first time in about 20 years.
Their reasoning for the updates sounds great…
So what’s the problem?
Well, there are a lot of unknowns… and the stakes are pretty high. This is our children’s development we’re talking about.
Personally, I have two big questions about these new milestones.
I’ve reached out to the CDC in hopes of getting answers directly from the source… I’ll update this as I learn more.
At the moment, however, there isn’t much information that’s available free to the public2.
Let’s start with what we do know…
The old CDC developmental milestones were based on the age at which 50% of children met a given milestone3.
This means that at the age listed, half of children had met a milestone, and half hadn’t. Essentially: an average.
The new guidelines are based on the age that 75% of children met a given milestone.
Why make this change?
They say that with a 50% milestone, a lot of people are inclined to take a wait-and-see approach since it’s still fairly common for children to not have that skill yet.
With a 75% milestone, there’s a greater chance that not meeting the milestone indicates a developmental delay, which should help encourage more early intervention.
Sounds good, right?
Well that brings me to my first question…
Will this change actually support more early intervention?
If it does, wonderful.
Getting children the support they need as quickly and easily as possible is the main priority.
But this is one of those big unknowns. We don’t know that it’ll work out like that.
There’s concern from speech therapists that this will result in less frequent early intervention instead.
Yes, with the 50% criteria, some might take the wait and see approach (although that’s already heavily discouraged).
But many people don’t wait and see, and they receive necessary early intervention sooner because they’re catching the delays sooner.
Especially with the lengthy waitlists in many areas, delaying the initial referral process could result in children missing out on a lot of valuable therapy time.
Parents have also shared concerns that their children who are currently receiving services wouldn’t qualify anymore based on the new milestones.
That one’s a bit more complicated…
The actual criteria for qualifying for services varies depending on the setting (school, outpatient clinic, etc.) and isn’t based specifically on these guidelines.
It’s unlikely that any kids currently in therapy would be disqualified because of these changes.
However, it is much less likely that a doctor will refer a child for therapy if the milestone guidelines say that the child’s development is right on track…
This could hurt a lot of people who are currently concerned about their child’s development and trying to get started with services.
So how will this actually play out?
Unfortunately, only time will tell…
And if they’re wrong about the benefits, how many kids will miss out on months or more of early intervention because of it?
My second question is about the process used to make these updates…
Did they use the same milestone sources in the old and the new guidelines, and just move the criteria from 50% to 75%?
If that’s the case, okay. The previous question is still a concern, but at least we know what we’re working with.
OR… did they use more recent sources on milestone data and move the criteria to 75%?
Based on the limited information available, this second option seems more likely.
Why would this matter? Wouldn’t newer data be better anyway?
Well, in most situations, using the most up to date information is best.
But, if they’re basing these new milestones on development data from the past 20 years, we could have some problems.
In their first official statement about these updates, the American Speech-Language-Hearing Association (ASHA) stated that it “reached out to CDC, expressing its concern about inconsistencies”4.
Why would there be inconsistencies in the data?
Child development studies have been going on for over 100 years…
And while we would expect the theories about how development happens to change over time, we wouldn’t expect to see much change in the actual process of development itself.
Historical data about developmental milestones from well-conducted research should still be valid today.
Unfortunately, data from the past 20 years probably wouldn’t be consistent with the data used for prior milestone guidelines.
How is that possible?
Well, in the past 20 years, we’ve seen a significant increase in rates of developmental disabilities and other chronic health conditions in children.
One area of concern is with language delays.
The number of children receiving public benefits for speech and language impairment increased 171% between 2004 and 20145.
We’ll address more recent updates on this in a minute.
But there are also other health conditions to consider…
Some diagnoses, such as autism, frequently coincide with language delays.
The prevalence of autism has increased from 1 in 150 children to 1 in 44 children since 20026.
Many other conditions aren’t as commonly associated with development, but may still contribute to language delays or share similar root causes.
We have research showing that there has been a massive increase in these types of childhood conditions as well, including ADHD, food allergies, and mental health disorders.
Just how big of an increase are we seeing?
Rates of ADHD diagnosis increased 42% between 2003 and 20117, with more recent reports indicating this impacts nearly 1 in 10 children8…
Food allergies in children increased 50% between 1997 and 20119, with current reports that 1 in 13 children has a food allergy10…
And for mental health, research from 2018 showed that 7.4% of children had a diagnosed behavior problem and 7.1% had diagnosed anxiety11.
To complicate things further, we’re just beginning to see the potential impacts of masking, social distancing, and increased isolation play out in children’s development.
Information is still very limited, and the political polarization around these topics makes it hard to find objective reports.
Some therapists say that there’s absolutely no evidence of negative impacts.
But other therapists are reporting increased numbers of children needing speech therapy12.
One clinic has reported over a 350% increase in speech referrals for babies and toddlers in recent years.13
It also appears to be impacting mental health… children’s hospitals’ reports of self-injury and suicide in kids 5-17 jumped 45% between 2019 and 202114.
Another 2021 study showed that anxiety and depression in children had doubled since the start of the pandemic15.
Finally, it seems global development may also be at risk…
A study at Brown University found a significant reduction in verbal, motor, and cognitive skills in children born during the pandemic versus those born in the prior decade16.
While our data on these topics is far from definitive, it does present some cause for concern.
But what does this have to do with milestones?
As rates of speech and language disorders and developmental disabilities go up (along with all the other health conditions that can negatively impact development), the average age that children meet milestones will rise as well.
That’s the problem with using newer data… whether from the past few years or the past couple of decades… milestones would be changed to reflect slower development in addition to raising the milestone criteria from 50% to 75%.
So my final question is this…
It’s not a question for the CDC, but for the parents and other professionals impacted by these changes…
If we are seeing slower rates of development in the past 20 years (as all these reports would indicate), what should we do about it?
Should we update developmental norms because slower development has become so common it’s now considered “normal”?
Or should we continue to look at the decades of historical data to see what optimal development looks like, and try to address the root causes that have resulted in slowed development and increased chronic health problems?
I’d be thrilled to find out that I’m wrong about the process used to update the milestones…
I hope the CDC did in fact use the same data from their old recommendations and just change the percentages.
But if that isn’t the case, every parent and healthcare professional will have a decision to make.
Will we accept updated norms based on a population whose overall health and lifespan* is in decline?
Or will we decide that common does not mean normal and isn’t good enough for our children?
Will we lower our expectations, or will we work to address the root of these problems so our children can experience optimal development and a higher level of health and wellness?
*That’s right, even before the pandemic, life expectancy at birth had been declining for three straight years between 2017 and 201917. It continued to decline further in 202018.
Like to see the sources for yourself? So do I. They’re all right here:
1. CDC developmental milestones: https://www.cdc.gov/ncbddd/actearly/milestones/index.html
2. Report describing the process for updating milestones (only the abstract is free to the public): https://publications.aap.org/pediatrics/article-abstract/doi/10.1542/peds.2021-052138/184748/Evidence-Informed-Milestones-for-Developmental?redirectedFrom=fulltext
3. Summary of updates to milestones: https://www.cnn.com/2022/02/18/health/developmental-milestones-children-guidelines-wellness/index.html
4. ASHA statement about updates: https://www.facebook.com/asha.org (posted 2/21/22)
5. 171% increase in language delays: https://leader.pubs.asha.org/doi/10.1044/leader.PA2.21032016.np#:~:text=The%20total%20number%20of%20children,Administration’s%20Supplemental%20Security%20Income%20Program
6. Increase in prevalence of autism spectrum disorder: https://www.cdc.gov/ncbddd/autism/data.html
7. 42% increase in ADHD: https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd
8. 9.4% of children have ADHD diagnosis: https://www.cdc.gov/ncbddd/adhd/data.html
9. 50% increase in food allergies: https://www.foodallergy.org/resources/facts-and-statistics#:~:text=The%20Centers%20for%20Disease%20Control,than%20tripled%20in%20U.S.%20children
10. 1 in 13 children has food allergy: https://www.cdc.gov/healthyschools/foodallergies/index.htm#:~:text=Food%20allergies%20are%20a%20growing,children%20in%20the%20United%20States.&text=That’s%201%20in%2013%20children,immune%20response%20to%20certain%20foods
11. Mental health disorders stats: https://www.cdc.gov/childrensmentalhealth/data.html
12. Ohio SLP on increase in cases: https://www.wtol.com/article/news/local/wearing-masks-may-have-disrupted-childhood-speech-development-experts-say/512-0b77cf98-d586-440d-8b2d-1220fd4ca523
13. Over 350% increase in speech referrals: https://www.wpbf.com/article/palm-beach-covid-therapist-speech-delays/38189805#
14. 45% increase in reports of self-injury and suicide: https://www.childrenshospitals.org/Newsroom/Childrens-Hospitals-Today/Articles/2021/11/Sounding-the-Alarm-for-Kids-Mental-Health
15. Anxiety and depression doubled: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2782796
16. Brown University study: https://www.medrxiv.org/content/10.1101/2021.08.10.21261846v1.full.pdf
17. Decline in life expectancy 2017-2019: https://www.cnbc.com/2019/07/09/us-life-expectancy-has-been-declining-heres-why.html
18. Decrease in life expectancy 2020: https://www.cnbc.com/2021/07/21/life-expectancy-in-the-us-declined-in-2020-especially-among-people-of-color-.html#:~:text=%E2%80%9CThese%20groups%20were%20getting%20infected,2000%2C%20according%20to%20the%20report
