With the recent changes to the CDC’s milestone checklists, we know that some parents have had questions about what changed, why they changed them, and what it means for their family. Check out our bonus podcast episode to get more in-depth answers and information!
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Mackenzie Johnson: 0:09
Hey, everyone. Welcome to The Science of Parenting podcast, where we connect you with research-based information that fits your family. We'll talk about the realities of being a parent and how research can help guide our parenting decisions. I'm Mackenzie Johnson, parent of two littles with their own quirks. And I'm a parenting educator. Today we are going to do a quick little bonus episode on a topic we've actually received a few questions about, and that is the recent change to the CDC milestone checklist that was earlier in 2022 earlier this year. And we're going to use the same approach to this episode that we do with all of them, taking a look at it from the lens of research and reality. And of course at The Science of Parenting, we believe that these things coexist, right. You don't have to pick between you know, trusting the experts blindly, we, or only trusting your instincts, we think that they can coexist. And so our goal is going to be to provide you with research-based and trustworthy information so that you can decide what it means for your family and make decisions for you and your children. So let's dig in, let's talk about the CDC milestone checklists and their changes. Now, for some of you, you might just be regular listeners and you're like, okay, I haven't heard what, like what, what are we talking about? So let's start there. What are we talking about? Maybe you've seen people talk or you've seen maybe on social media or something or heard somebody. So let's talk about what's actually happening. So what you need to know first is that in 2004, the CDC, the Center for Disease Control, they released a kind of campaign and they called it, "learn the signs, act early." And it's basically a program of these developmental checklists, which are just the types of tasks or the type of things that our kids are doing at different ages. And it included things like developmental warning signs, like when it was time to be concerned about like, if your child's not walking yet, if your child's not talking yet if your child can't stack blocks yet. So it gave us the kind of some warning signs. It gave us a lot of messages to make sure we were acting early to address these concerns. And then also it gave us some developmental tips and activities. So things we could do to support our child's development. The checklists were originally developed with a few reasons in mind. One to help us as parents recognize that, like, what should my child be doing at this age? We don't all just know that inherently. You have some personal or professional experience that can help inform that. But it gave us some information. So a place to start about what was typical development. Another purpose was to help kind of in the relationship between families or parents and their doctor. So that is really, who's typically involved in monitoring kids development is like their family physician and their parents. And so part of the goal was to really, in those conversations, help kind of elicit or help draw out parent concerns. When you look at this checklist, is there anything here that you would have a concern about for your child? Right. That might be a way that a doctor had used one of those checklists. And also it was meant to kind of improve the conversations that parents and doctors were having about kids' development that they were on the same page or had the same literal checklist or starting point to look at. But then it also, another goal of it was to support the idea of kids getting additional screening when they needed it. So at what ages should we have concern and should we kind of refer families or refer kids to get more services? So there's really, it's partially for doctors that serve families, and it's partially for parents to talk with their doctors or whoever they have in their world that they can express these concerns to. So that was back in 2004, they released the "learn the signs act early" program. And one part of it was these developmental checklists that are free, can be accessed online. That doctors were often using. So that's what it was in 2004. Since then and in this year in particular, this was underway for a few years, but in 2022, the Center for Disease Control released that they had made some changes to those longstanding checklists that had come out in 2004. And the purpose of the checklist remains the same. It's always been to help doctors and parents keep an eye on children's development -development -and to facilitate that ongoing conversation about it at children's you know, like, well child checks or physical health checkups or whatever, you might refer to them as. But that there's a place for a conversation between a doctor and a parent. These checklists were never meant to be. And they aren't now meant to be kind of a screening tool for like a delay or for a diagnosis. That has never been their purpose. There are actual screening tools like the ages and stages questionnaire, which is the ASQ or similar tools that are physically to help us figure out, like, does this child have a diagnosis? Does this child have something going on? This is not that. This is a different thing. So it's a checklist of a place to start for what is typical development. And so it might be used to maybe refer a family to go get an actual screening done. So, this is just kind of to monitor and to facilitate conversation. So the old versions were, that was the purpose. That's the case with these updated versions too. So the other thing to understand about the changes that the CDC released is that actually it came from a recommendation of experts from the American Academy of Pediatrics. So they refer to themselves as an expert working group from the American Academy of Pediatrics. So several doctors who serve patients, families, children, and then they all kind of came together to do this work, some research, some reviewing of the literature, and then to make some recommendations. So according to an article that, that working group from the American Academy of Pediatrics that they published in the peer reviewed Journal of Pediatrics. They said the goals of the group were to identify evidence informed milestones to include it as easy checklist to clarify when most children could be expected to reach a milestone. So notice, they were trying to clarify, so reduce confusion. And then also that they want it to support doctor's judgment regarding referring kids to screening at certain ages. So this was helpful for families and for doctors, they wanted it to clarify some things, make sure they were research-based and then also kind of support that opportunity to refer families when they need it. So when they have a concern. So FYI, just for this episode here I'm going to be referring to this article a lot. That article that was published in pediatrics from that expert working group that really influenced the changes that happened on those checklists from the CDC. I'm also, I'll drop a link to that if you would like to check it out. There's this cool little, well, I think it's cool. Maybe it's dorky, there is a little like video abstract of one of the authors talking about the article that they published. So you can go look at that, on that webpage where the article is. But we'll drop a link to that in our blog post, too, that you can look at, look that up. So before we dig into what actually changed, the other thing that I want to say is this can be a really significant conversation for parents of kids with special needs. So if you are a parent of a typically developing child that maybe you've never had a concern about their development you might be like, okay, what's the big difference? But really there are implications for families. If they've had concerns about their kids' development the experience that they have in having conversations with their doctors, maybe in trying to get referrals to a specialist or in you know, even just the services or the screening to find out, does my child have something going on or are they just a late bloomer? And so this can be a really significant conversation, but we know for every parent it might, that might not be your experience. So a little bit of context this is a really important conversation for a lot of families. So now let's dig into what actually changed. So you're like, okay, 2004, the originals, and now 2022, the updated. What changed between them? What did they do? So I found nine things in the article. It's possible I missed some. But I did choose the, I did read through that journal article as well as a few others, and I found nine things that have changed. So again, Based on the recommendation of that expert working group from the American Academy of Pediatrics, but also updates that they learned from these checklists being used for 15 years, right? People were using them. They're like, oh, this doesn't work very well, or this wasn't great. So there was a lot of things that inform these changes. So the first one of something, a few things they did to remove, to reduce confusion. One is that no longer can a milestone be listed on more than one age checklist. So for example there might be something on the 24 month checklist and on the 18 month checklist in the old version. And so maybe it was related to the number of words that kids said or something they're doing with their physical development or their language or their cognitive development, like what they understand. Well in the old version, that could be on more than one list. And so if you were looking at the lists you're like well, where, when do I get, when do I know when to be concerned? Right. If I see this milestone on two different ages, I don't know what to expect. What does that mean? So that was something that was in the original version that they removed in the updated version. Milestones have been specified to a specific age. No longer on more than one list. The second thing they did to reduce, reduce confusion is the got rid of some vague terms like "children might begin to..." and I don't know why this one sticks into my mind. I remember reading children might begin to like pass an item from one hand to the other. And I was like, begin to pass an item? Like they start passing it and then they stopped midway? Or they do it occasionally, or they almost can do it? Like what is begin to do this mean? And so there were, there was some phrasing like that in the original checklist that they kind of clarified and made much easier to understand. The other thing that they did is they removed from the old checklist, those warning signs. So like the when to be concerned. And there's a reason for that. That's actually going to be the last thing that I tell you about in the changes that were made, but they remove that warning sign sections in the new update and the new checklists. The next change. So this is number four, is that they provide direct citations in the new checklist to specific studies that backup why that milestone belongs there. So when you look on a checklist, there's going to be some physical, some cognitive, emotional, language, right? There's going to be all these different kinds of milestones. And when you look at it, there are specific studies that inform why each of those bullets, why each of those milestones is there. That wasn't the case in the old version. So they didn't really know, like what if research changes? What if this new huge study comes out and we learned something new, but we weren't really tracking where we're getting our information initially. And so in the new version they are, and the updated versions of the checklist, it's like, Hey, we have this many studies that say, kids walk at this age or have this much language at this age. So that's a really powerful thing, especially I think, right. That's a part of our belief that The Science of Parenting is that research component. And so those direct citations is a good thing. Another change related to the research and the citations is in the original version, there was some, actually most of the research was based on like one type of group. So there might have been a lot of white people or a lot of middle-class people or in those studies there might've been more parents who are educated. And basically when you looked at, when do those kids do like achieve certain milestones, it wasn't giving us a full picture. And so the studies that it's based on now, this expert working group made sure that more diverse populations were captured in those studies to make sure that everybody's experience is represented in calculating what, where that timeline should be for those developmental milestones. Now. Number six. They added two checklists. So from the original, right, they maybe had on it six months, 12 months, et cetera on down the line. But when it comes to our health systems in the United States, many kids are having well-child checks also at 15 months and 30 months. And before there weren't checklists for those. So there would be a CDC developmental checklist for a doctor to use with their families when they'd come in at all of these ages, except those two visits. Well, so when they were redoing them, they add a checklist for the 15 month visit and the 30 month, but visit it. So you can also find those. And they weren't there before. So then number seven, and this one is really to the benefit of the conversation, right? That's part of the purpose is the conversation between parents and doctors, and so on these checklists there's open-ended questions, there's recommendations to open discussion between parents and doctors about that child's development. You know, when to have concerns or act a certain way to ask about milestones, to facilitate that discussion in a positive. And then number eight, I get real dorky about, I get really excited about one of the other things they did is they made recommendations to researchers based on these milestones. And so they did, you know, reviewing all of these studies of all these different milestones, like really specific things like how many words kids say at a different age or when they pass an item from one hand to the other or when a child can wave or smile. Right. All of those things are milestones. And they looked at all of those studies and they made recommendations for where researchers should do more research. Right. So which kinds of milestones do we maybe not have so many studies to inform that information that we share with parents? So they made recommendations or researchers like, Hey, study more of these. So I think that's a great thing that informs the scientific community to do more research. And then number nine, the final and biggest I saved it for last. This is the one that's kind of generated a lot of conversation. And one of them is the biggest change and update is that they moved the milestones on the old checklist they were at, there were an average. So when it said children walk at this age, that is an average of, if you take a hundred kids, 50% of them could walk by this age. That's how the old checklists work and the new checklists, they changed it. So that it's at a point when 75% of kids might walk or when 75% of kids do this skill. Now there's a few reasons for that. But I want to make sure that we have an understanding of what that changes, right? So the average before, when 50% of kids could do this thing, they've now moved it to when 75%. So in a lot of cases, in most cases, when you're looking at a milestone, if on the previous versions, it was at 12 months. Now it might be on 15 months or now it might be on 18 months because it was moving to when a bigger majority of kids instead of just half. All right? So it's no longer an average, it's now when there's more of a majority. That 75%. So let's look at why they made that change as well as some of the other changes. So that changed from 50 to 75% has really been a topic of conversations. I know there was professional organizations, particularly like speech therapists who expressed some concerns about it, worried that it would affect the way that kids get services or qualify for therapies or things like that. And remember, that's not the purpose of these checklists, these checklists aren't screening tools. They're just a sign to know when to be concerned. And so according to the article in Pediatrics, that journal article we were talking about, there's several justifications for that change from an average to a majority. And when they looked at the list at the age where 50% of kids were expected to do a task, what often happened is if you were a family and I have been, I've been this parent I've walked into a conversation like a well-child check with my doctor and I've walked in knowing I want to ask them why my child's not doing this yet. Like I have a concern about this. And so what would happen is parents would express a concern about their child's development and a doctor would often just say, well, let's just wait and see. So people talk about the wait and see, and part of the purpose was to reduce that. But it makes sense when we think about it, if 50% of kids can walk by 12 months and I'm making that up, I didn't look that up on the checklist first, if 50% of kids can do this milestone, that means half of them are going to do it after. Right. And so for a doctor, they're like, well, I mean, chances are your kids just a late bloomer. Okay. And so they would often just be like, oh, well, we'll just wait till the next we'll keep an eye on it. Right. But for parents, we had real concerns. Right. My concern was still there, even if I was just supposed to wait and see like, how I don't know if I'm just waiting indefinitely, when will my child ever do this thing? Like, will my child ever walk? Am I waiting indefinitely? Like when should I be concerned? I don't know. Are we going to remember to follow up with it at our next appointment? And it can leave me as a parent feeling, like not confident, and unheard too, right? That wait and see, could impact the relationship between a parent and a doctor when they were supposed to be on the same team for their kid, right. They want to check on that child's development. So part of this, a big part of the change was if we move it to when the majority of kids, when the 75% of kids can do this task, if a child is in that 25%, they're not meeting that milestone. We know it's time. We know it's time to refer. We know it's time to ask for additional therapies or services or screenings, whatever that is. And so it gives us a clearer picture, both as parents, and as doctors, a clearer picture of when it is time to be concerned and when to address it. So at 50%, most of the time was like, well, we'll just wait. And that meant for some kids who did really have a delay, they weren't just late bloomers. They might have a diagnosis going on. And a condition that could have been addressed with therapies or with services or interventions. It wasn't getting that because doctors are like, well, let's just wait. And that just became the thing that it was easiest to say and do we'll just wait and see. We'll just wait and see. And so the 75% gives us a much clearer picture and a much clearer perspective to be like, no, my child's not meeting this now. Now is the time to do something about it. So that's a really important part of it. Another thing is that with when they were at 50%, it could cause a lot of concern for parents. So I can say I had a late bloomer. My first child had very early milestones. And so my, then my perspective was skewed. Like, oh yeah, we just have kids who do early things. Haha got in my own head about that. Because yeah, then my second was born and he was not in a hurry to do a lot of those things. He actually walked about six months later than my older child had. And I remember being like, but it says on this list, he should be. I was I was concerned, right. It was throwing up red flags and it cost a lot of concern and panic that it really did just need time for him. But I didn't know when the time to be concerned was when things were at 50% and at an average, I didn't know when the time was to really push my doctor about no, no, no. We need to figure this out. As a parent, I would have felt a lot more confident knowing like my child's not doing this by this age. That's what this checklist is telling me is that now's the time to do something, not to just wait and hope it gets better. And so it's also really, it benefits parents a lot. If they do have a concern. And then in a direct quote from the authors, they also give this reasoning, "the previous checklist provided insight into child's- children's typical development, but they did not provide clarity for parents, pediatricians, or other early childhood professionals about when to be concerned or when an additional screening might be helpful. So they gave us information, but they didn't give us really the check mark that we needed to say, now's the time they didn't have the, they weren't meeting that purpose of learning the signs of when to act early, because we didn't know when. We were waiting and seeing. So that 50%, it's no longer an average, it's now when the majority of children do this it's at that 75%. So that was a big one. That was a lot of conversation around these changes with the CDC. Another one that I've heard a couple people talking about is that crawling is no longer a milestone and this has been kind of controversial. I've seen a lot of people talking about this, like on social media that they took away the milestone of crawling and in the, in the article. From that expert working group in pediatrics they gave a couple of reasons for it. One of them is that crawling the age range for when kids do it varies so much that the percentage really wouldn't give us a good picture. The other thing is that it's a milestone some kids skip altogether. So if we had it in this new model of 75%, if your child's not meeting this by this age checklist, this is the time to be concerned. If we had crawling on there, okay, my, one of my kids never crawled. They did kind of like a modified, but scoot, which I have a lot of videos of that I love. But yeah, they never crawled. And so if we're on this checklist of now's the time to be concerned. So they removed that milestone altogether, they have kind of alternative like wording and like looking at that idea of like a child being mobile, but it's no longer like kids should 75% of kids crawl by this age because it's a huge range of when kids do it and not everyone will. So there are, there's a lot of reasons for these changes and a lot of research and time and years in the making have, has this update been coming. In fact, I actually wrote a paper in grad school. I, gosh, that probably would have been like in, 2019, maybe? Maybe before that. And, but funny enough, the paper topic that I chose was closely related to these CDC milestone checklist and other checklists like them. And it was basically, I, part of what I needed to do was look up the criticism that people had related to that. So there was a 20, one of them was a 2013 study by Kartner and Keller, and they shared that many studies that were used to do the first round of the 2004 versions of the childhood milestone checklist that a lot of those studies did not represent diverse experiences. Did not include diverse representation. So again, when looking at those checklists, there were whole groups of people that weren't considered. Another component of that is that, okay, got to get a little dorky on this, part of what I looked at in that paper is like, do kids from different countries do things at different times? And so there can be certain practices in a culture, right? Certain parenting practices that might encourage or discourage certain developmental milestones. And it's like, if we're not including that in the full picture of when kids develop and do things it's not informing our understanding related to that. So that was a 2013 study. Another criticism of the. Original versions of the CDC milestone checklist, Sheldrick and colleagues in 2019, they were making this recommendation to change instead of 50% to do like a norm is what they call what they call that. But to change instead of doing 50% to update it to basically what they have now. But they were saying because they were expressing the concern about how the confusion was for parents and that there just wasn't a lot of clarity in the original versions. And then another criticism, one was in a 2007 study and other one in a 2019 article. They said that the list of milestones weren't cited, right? That's an update they made, but that means we don't know what that information was based on. And they said ages for specific milestones, like walking, like when you can throw a ball like when you can sit up unassisted -that there were really inconsistent across different sources. So the CDC might say one thing and another organization might say another and the American Academy of Pediatrics might say, right. And so there was all of this confusion and that it wasn't clear. And so these were criticisms, yeah, you can see that these were years in the making. A 2007 study, a 2013 study, 2019 articles. And that this was... some people have expressed concern that they thought maybe, well, the CDC made these changes because of like the COVID-19 pandemic and that this was not related to the pandemic that these, this work of reviewing the literature and this planning and this thought process and the need to update them. That was in the works long before the COVID-19 pandemic began. So if they were unrelated, timing just happened to fall around the same timeline. But there was a lot of research and there was criticism, right. We'd been using those CDC checklists for like 15 years. And so yeah, people knew what wasn't working and so they needed to make those updates. And a lot of people have had positive feedback related to, you know, clarifying that language. Like I'm so glad none of them are going to read "may begin to..." I remember being like, I don't know what "may begin to" means on a developmental milestone. So there's a lot of changes and a lot of reasons why they made those changes too. So the big question that leaves us with as parents is what does this mean for me? What does this mean in my own reality? How does this checklist really affect my life? And so I have three things that kind of come to mind for parents and what this means in your daily lives. So one, it does not change the way that you continue to have conversations with your family doctor about your child's development. You still have those conversations. So continue to have those conversations, continue to share your concerns. You know, if you are wondering about something, have those conversations, you, what is new is that you can use these checklists in a different way. You can use them kind of to back you up. If you feel like you're not being heard, or if you have a concern that your child's doctor you don't feel like is acknowledging. These can kind of back up that conversation you have and the perspective you bring in. The other thing to think about that this can affect is being prepared before you go to a doctor visit, you know, especially this is a challenge, a lot of parents of special needs kids face is those conversations with doctors or with therapists or whoever they're getting services from and being that need to be assertive to advocate for your child. And so, you know, brushing up on those assertive communication skills which we have lots of information on at Iowa State Extension and Outreach, but being prepared to have those conversations and that you can use this to kind of back you up as good reason to do so. So continue to have those conversations, use this as a tool to facilitate that. The second strategy or suggestion that I have is to download the CDCs milestone tracker app. I've been talking about that since that season that we did, and I discovered it the season on child development and I just, I use it still with my kids and I love it so much. And basically it's going to ask you those really specific checklist questions, and you're going to say, yes, my child does this. I'm not sure if they do that or they don't do that. And then the cool thing about the app is then later on, like, let's say a month later, it'll pop up a reminder, like, "Hey, last time we checked in, you said your child wasn't doing that yet. Are they doing that now?" And so that's going to help you keep an eye on your child's development if you do have concern. And that's another tool you can use, if you are talking with professionals about your child's development. And so the CDC milestone tracker app that is updated with the new checklist since those were released. And then finally, as a parent, make sure we're going to keep engaging with our kids, right? We're going to keep playing with them. We're going to have conversations and we're going to keep those simple daily routines. So what our daily life looks like might not change, but it can impact the way that we have conversations about our child's development. And I see that as a really great thing. So I want to say, thanks for joining us today on The Science of Parenting podcast. Remember, you can join us on social media, Facebook, and Twitter @scienceofparent. You can see our content in your feed. You can subscribe, get notifications when we release new things. And of course stay caught up with us between seasons. So please do come along with us as we tackle the ups and downs, the ins and outs and the research and reality all around The Science of Parenting.
Anthony Santiago: 28:31
The Science of Parenting is hosted by Lori Korthals and Mackenzie Johnson produced by Mackenzie DeJong with research and writing by Barbara Dunn Swanson. Send in questions and comments to firstname.lastname@example.org and connect with us on Facebook and Twitter. This institution is an equal opportunity provider. For the full nondiscrimination statement or accommodation inquiries, go to www.extension.iastate.edu/diversity.ext.