So… What happened?
The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) created the Learn the Signs. Act Early. program in 2004. The program provides checklists of infant developmental milestones to determine the need for developmental screenings. After several years of research and discussion, the AAP updated these guidelines in February 2022.
A primary update involved adjusting key milestone benchmarks for children. The milestones now represent what 75% (most children) are able to do at a certain age, instead of 50% (the average number of children).
The AAP believes that because the previous milestones were expected for only 50% of children, this often led to a wait-and-see approach for screening and treatment. The new guidelines aim to make it easier for clinicians to determine when additional screening is needed. If a majority (75%) of children are expected to hit a milestone at a certain age, those who do not will more clearly need screening.
By and large it seems that the experts are NOT on board with many of the changes that have been made (Dr. Mona had a number of interesting experts on her podcast to discuss the changes).
“As speech-language pathologists, we’re happy to see many of these updates, such as the removal of confusing and nonspecific language, as well as the addition of two new checklists for ages 15 months and 30 months, but while we wholeheartedly share the AAP and CDC’s goal of discouraging a wait-and-see approach for screenings, we have some concerns with the study’s methodology and findings,” says Leanne Sherred, MS, CCC-SLP and Expressable’s co-founder.
Sherred goes on to note that language development is a core part of these milestones and – shockingly – speech-language pathologists were not included as subject matter experts in the revisions. “Our concerns center on the potential impact to early intervention, which is proven to help children more quickly reach expected communication milestones,” says Sherred. “In fact, studies have shown that the benefits of early intervention outweigh the costs at a ratio of 7:1. The longer intervention is delayed, the higher the chance that children will fall further behind their peers–and need more treatment as a result.”
In addition to shifting the benchmarks from 50% to 75%, the new milestones push out several key goalposts, such as children saying 50 words by 30 months instead of the previous 24 months. “The remaining 25% of children who don’t reach the 50-word mark by 30 months may not be likely to have progressed developmentally on their own. These guidelines essentially delay intervention for this at-risk population, which could have harmful consequences,” says Sherred.
She outlines the below as examples:
- A communication problem that may have required 6 months of speech therapy if caught at an earlier age might take double the time if diagnosed later.
- Children entering preschool with untreated speech delays may have trouble communicating and even exhibit behavioural problems that speech therapy could have helped prevent.
- Delayed diagnosis can affect academic success later on. Children who do not have age-expected language comprehension/expression and phonological skills are more likely to struggle with early literacy.
Finally, there are concerns regarding the sourcing for some of these changes, such as the 50 words by 30 months milestone. “None of the AAP’s sources seem to support this number, and in fact, multiple cited sources list 50 words as a 24-month milestone. We’d like to better understand the evidence for these revisions,” says Sherred.
In summary, she concludes that while the AAP’s intentions are noble in trying to prevent the wait-and-see approach, we believe these new guidelines could have the opposite effect, exacerbating the problem.
“As the AAP has stated, further research is needed to understand if these checklists will indeed support early identification of developmental delays. In the meantime, we continue to champion the value of early intervention, especially before age 3. If you have any concerns at all about your child’s development, talk to your pediatrician and ask for a referral to a specialist.”