Changes to developmental screenings

For many years I have used developmental screenings at most well visits of infants and young children. (Only most because there have been no screenings for 15 months or 30 months of age.)

After discussing the results of the screen and other things they are seeing at home, as well as assessing the child throughout the visit, I often find myself reassuring parents that their child seems to be developing normally and that the skills not yet attained can be worked on at home. Unfortunately, many parents fail to be reassured and leave the visit worried unnecessarily about their child.

I use the results of the screenings to further discuss development, and often joke that in school teachers teach to the test, but unless parents have a degree in early childhood development, they don’t know what to teach or what to anticipate. The screenings are a great way to open the conversation and to show what types of things they can do at home to improve skills. I often give online resources and our local Parents As Teachers information to arm worried parents with tools.

The screenings are helpful to get parents thinking about what they can do to stimulate their child’s development, but it does lead to excess worry - and no parent needs more things to worry about!

The screenings have not been great at identifying which children would benefit from immediate services and in which cases a “wait and see” approach is best. It is only when a child has several significant variances in development that I become concerned enough to consider further developmental screenings or to refer to early childhood services. I don’t want to miss the opportunity to send a child for necessary screenings, but there are limited resources for the children who really do need services, and the questions simply did not do a great job at identifying which kids to refer for services.

I’m excited to see the new recommendations and will summarize why the changes were made below.

Parents can access all the new developmental milestones on this CDC page.

I am not sure when online versions of the new screenings will be available. I hope soon! Until then, you can use the CDC Tracker App.

And no, these changes are NOT due to anything pandemic related. 

The need for change was identified long before the effects of infections SARS-CoV2 was a concern and before masks were used in daycares and schools.

The data reviewed during the writings of these new milestone screenings is from pre-pandemic times.

Three areas for improving the checklists were identified by the CDC.

1. Criteria for checklists used for surveillance needed to be established to evaluate the existing CDC checklists. Previous milestones were based on expert opinion, not data.

2. Milestones previously were based on expert opinion of what 50% of a child should do at any given age. This led to many “wait and see” approaches, since half of kids would not be expected to do a skill at that age. The new milestones would be research based and represent milestones above the 50th percentile to ensure that most children would achieve the milestone by a given age.

3. New checklists for the 15- and 30-month well visits were needed.

The committee re-categorized milestones into 4 developmental domains:

1. social emotional

2. language/communication

3. cognitive

4. motor

Clarification of the age a milestone should be reached

Previous checklists had repetition of milestones across various ages, which introduced confusion and led to unnecessary worry.

As a pediatrician, I know that half of kids did not reach some of the suggested milestones at any given age and many questions would be repeated on the next screening. Unfortunately, parents do not know that only 50% of children should have some of the skills asked, and even with reassurance that the child seems to be developing at an expected pace, many parents worried if their child did not yet master each question asked.

To develop the new milestone recommendations, the committee reviewed 2-3 age groups at a time. This also helped to identify skill progressions.

Better ways to ask questions

When I discuss developmental screening results with parents, I often find that they misunderstood a question, so the answer is not a true reflection of what the infant or child can do.

I’m happy to see that the committee evaluated the way the questions were asked to get a better understanding of the skills across various cultures and reading levels. The new questions include examples and should help to minimize confusion.

Fewer (but more appropriate) questions

Parents will be happy to learn that there will be fewer questions on the surveys.

Previously, CDC had 216 milestones across 10 checklists. There are now 12 checklists since 15 and 30 month lists were added.

There are now 159 milestones in these 12 checklists, including 94 original CDC milestones and 65 new milestones. This represents an overall decrease of 26.4%, with the average number of milestones per checklist decreasing from 22 to 13.

Fewer questions are possible (even with new questions asked) because they removed duplications (the same milestone on multiple age surveys) and the milestones that had no validated evidence were removed.

Vague terms, such as “may” or “begins,” were removed and the milestone was put in the appropriate age category at which 75% of children would be expected to meet that milestone. For example, “Begins to pass things from one hand to another” was removed from the list of milestones at age 6 months and was included as “Moves things from one hand to her other hand” at age 9 months.

Special thanks

I had started this post to debunk online chatter claiming that new guidelines were needed because of masks (or brain damage from COVID infections) and was happy to see this thread from Dr. McCafferty. The last link in her thread helped me to better understand the changes discussed above.

Sometimes it’s hard to find the information we are looking for - there is an overwhelming amount of information online - some good and some not. Before sharing any information, we should all try to find reliable sources so we don’t share misinformation, even if the information seems to align with our views.

In this situation, I wanted to debunk that the changes were made in response to kids not learning sufficiently during the pandemic. I knew that they were based on many years of data, but this article helped to give more context.

My early searches led to several news releases, such as CDC, AAP update developmental milestones for developmental surveillance program and the updated CDC Developmental Milestones page, but I had not found documentation of the reasoning behind the changes until seeing her thread. Thank you, Dr. McCafferty!