ASHA Comments on CDC and AAP Developmental Milestones Updates

ASHA has received significant number of comments from ASHA members regarding the February 2022 update of the Learn the Signs. Act Early. milestone checklists by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP). ASHA was not involved in the revised milestones, and has met with both groups. AAP and CDC shared the below information to provide to ASHA members. ASHA reviewed the AAP/CDC changes to ages for particular milestones, and believes that the checklists may be used in conjunction with a number of additional clinical tools to facilitate early intervention. However, ASHA remains concerned that some changes in the checklists will slow and/or inhibit referrals for early intervention.

Some notable changes made by AAP/CDC in the developmental milestones about which ASHA members have expressed concerns include the following:

The criteria established by the AAP working group and the milestones added for the 15- and 30-month health supervision visits resulted in a 26.4% reduction and 40.9% replacement of previous CDC milestones.
One third of the retained milestones were transferred to different ages; 67.7% of those transferred were moved to older ages.
Approximately 80% of the final milestones had normative data from ≥1 source.
Social–emotional and cognitive milestones had the least normative data.
These criteria and revised checklists can be used to support developmental surveillance, not the clinical decisions during developmental screening and assessment.
Gaps in developmental data were identified, particularly for social–emotional and cognitive milestones.
Checklists were translated in multiple languages. Language development is not universal across all languages.

Information From the CDC

CDC’s Learn the Signs. Act Early. program funded the AAP to convene an expert working group to revise its developmental surveillance checklists—not developmental screenings. This project is supported by CDC of the U.S. Department of Health and Human Services (DHHS), as part of a financial assistance award totaling $100,000, with 100% funded by CDC/DHHS. This program has been in existence since 2012. CDC met with leadership from ASHA on February 28, 2022, to better understand the concerns of their members and to clarify the purpose of the Learn the Signs. Act Early. milestones checklists. CDC shared the following information with ASHA.

One of the subject matter experts who supported the review of evidence and revision of milestones was dually trained as a speech-language pathologist and then went on to become a developmental behavioral pediatrician. AAP also had the chance to consult with another speech-language pathologist in the review and revision of the tips and activities for supporting early development.
The milestones are evidence-informed—they were not developed by the expert group; rather, AAP conducted a review of evidence of existing milestones.
The aim of AAP/CDC was to make the milestones more clearly actionable, resulting in increased developmental screening and referral. But the milestones are only one part of these communication tools. Each checklist provides families with open-ended questions to prompt consideration and discussion of their child’s development, an “act early message” providing information on how to address concerns—including information for families to find their state’s early intervention program, reminders for when developmental screening is recommended, and tips for promoting their child’s development.
These milestones are NOT intended to impact how/if children qualify for services.
Developmental monitoring using resources like Learn the Signs. Act Early. milestone checklists is just one small part of what is recommended in terms of developmental tracking during early childhood. For example, for children between the ages of 9 and 30 months, universal developmental screening (general screening and/or autism-specific screening) is also recommended at the 9-, 18-, 24-, and 30-month well-baby/health supervision visits.
CDC looks forward to engaging with ASHA in the future.
With regard to the concern that language milestones are too low, CDC’s Learn the Signs. Act Early. materials for tracking developmental milestones are not developmental screening tools, nor are they standards or guidelines; they are communication tools that aim to promote developmental monitoring; encourage conversations between parents, doctors, and early childhood providers about child development; and increase developmental screening. CDC has not lowered the standards of early childhood development. The revised milestones should not impact how children are evaluated or how they qualify for services.

Information From AAP

ASHA met with AAP on March 7, 2022. AAP described their contractual relationship with CDC to review and update the Learn the Signs. Act Early. program. AAP did not ask ASHA to recommend speech-language pathologists to work with them as they updated the Learn the Signs. Act Early. program. AAP stated that they have enjoyed partnering with ASHA in the past on developing articles for consumers for its Healthy Children website and conveying messages regarding children wearing masks. They stated that they are open to collaborating in the future. They also shared that they have made the article, “Evidence-Informed Milestones for Developmental Surveillance Tools,” which appeared in Pediatrics, open access in order to further communicate their actions and intentions. AAP does not have plans to make additional edits to the Learn the Signs. Act Early. program update. They welcome ASHA sharing information about the program with its members.

Developmental Milestones on ASHA’s Website

ASHA's Developmental Milestones: Birth to 5 Years were published in November 2023.

ASHA reviewed its developmental milestones (How Does Your Child Hear and Talk?) and determined what updates were indicated. In addition to updating the communication (speech, language, hearing) milestones, feeding and swallowing milestones were added. These developmental milestones and tips are designed to assist parents, families, and caregivers with information regarding developmental skills.

ASHA’s published milestones in the How Does Your Child Hear and Talk? series was updated in 2015. This information was developed to help caregivers learn about communication development and to provide them with a list of easily recognizable skills that most children will achieve within a given age range. These age ranges were determined based on published normative data regarding these skills. The data that ASHA references were collected prior to the pandemic and did not include children wearing masks for any period. Acquisition of language is not a singular path. Variations may exist based on culture, language(s) used, amount of exposure, and differences in communication or neurodiversity. The lack of acquisition of milestones do not equate to a disorder but, rather, may denote a need for screening by a developmental specialist.

ASHA’s Recommendations

ASHA members should continue to use screening and assessment tools that are culturally and linguistically appropriate—and not developmental milestones—when making clinical decisions regarding early intervention for children.
ASHA is willing to collaborate with both CDC and AAP in areas that are relevant to speech, language, cognition, communication, hearing, and feeding/swallowing skills.
ASHA is willing to (a) collaborate with both CDC and AAP in their work on CDC’s Learn the Signs. Act Early. program and (b) provide additional tips as well as culturally relevant and neurodiverse-affirming resources.
ASHA is an active stakeholder in providing parents, families, and caregivers with information that facilitates development and retention of skills. Checklists and milestones are not inclusive of multilingual and neurodivergent children who may have differences in acquisition of milestones.
ASHA members should encourage parents, families, and caregivers to seek the expertise of speech-language pathologists if they have any concerns regarding how their 1- to 5-year-old child communicates or swallows. Speech-language pathologists will provide guidance and strategies to facilitate their child's communication development if the child does not exhibit significant delays that warrant early intervention. Audiologists should be contacted if hearing is a concern. ASHA’s goal is that children enter kindergarten equipped with requisite skills necessary to learn.