Frequently Asked Questions: CDC and AAP Developmental Milestones Updates

In February 2022 the Centers for Disease Control and Prevention (CDC) published revisions to the developmental milestones used in the "Learn the Signs. Act Early" initiative. ASHA posted a statement and then followed up with comments. Some questions asked by ASHA members are answered below.

• Was ASHA involved in the revisions of the CDC’s Learn the Signs. Act Early. Milestones?
• Are there discrepancies between the CDC’s announced changes and ASHA-published milestones?
• How are ASHA-published milestones developed?
• Do you disagree and/or are you concerned about these changes from CDC and AAP?
• Will these changes impact how children qualify for services?
• What do you recommend for parents/caregivers, especially as they may be presented with conflicting information?
• How are children evaluated for speech and language disorders? Is this based on not meeting published milestones?
• When did ASHA last review and update How Does Your Child Hear and Talk?
• How are ASHA-published milestones developed?
• Does ASHA’s publishing of milestones represent an endorsement of them or an official ASHA position?

Was ASHA involved in the revisions of the CDC’s Learn the Signs. Act Early. Milestones?

No. Once ASHA learned of these changes, Association leadership met in early March with CDC and AAP representatives (since 2012, the CDC has funded AAP to work on the Learn the Signs. Act Early. milestones, and AAP convened a work group that implemented the review process). ASHA shared staff and member feedback regarding the revisions and expressed strong interest in participating and sharing SLPs’ expertise, knowledge, and perspectives in milestone reviews and revisions in the areas of speech, language, and feeding/swallowing.

Are there discrepancies between the CDC’s announced changes and ASHA-published milestones?

A handful of the revised speech and language milestones included in the Learn the Signs. Act Early. checklists do not align with what is included in How Does Your Child Hear and Talk?, an ASHA publication. Additionally, some milestones within these two resources are not exactly the same but don’t necessarily conflict either (e.g., ASHA-published milestones say, “Puts 2 words together, like more apple, no bed, and mommy book” between ages 1 and 2 years, whereas CDC–AAP state, “Says at least two words together, like more milk,” at age 24 months). How Does Your Child Hear and Talk? intentionally presents milestones in a range format—to reflect that not all children develop at the exact same age. It’s also very important to emphasize that speech and language skills/development may differ based on culture, language(s), geography, neurodiversity, and other factors.

How are ASHA-published milestones developed?

Milestones published by ASHA (through its How Does Your Child Hear and Talk? series) were 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 findings from published studies (a list is available on ASHA’s website). This was last updated in 2015.

Do you disagree and/or are you concerned about these changes from CDC and AAP?

ASHA appreciates the work of CDC and AAP and the intent of the changes, which was to identify more children with developmental disorders earlier by bringing additional clarity to milestones demonstrated by 75% or more children. It is ASHA’s understanding that both groups received feedback that presenting “average age” milestones (that is, skills in which 50% of children will achieve by a stated age) can be confusing to professionals and families—given that a skill that half of children have not yet acquired may not necessarily be a sign of a disorder. They believe that this promoted a “wait-and-see” approach. However, ASHA also is very conscious of what many of its members report: that children are already being referred to them later than they optimally should be. ASHA members worry that any reassignment of expected skills to an older age will entrench the “wait-and-see” approach.

ASHA also remains concerned that the checklists were translated into multiple languages. Language developmental milestones are not universal across all languages. Tips for families to enhance their child’s communication skills at home should be culturally relevant and may not translate across languages. Given the rate of disproportionality in the identification of children from linguistically diverse backgrounds compared to monolingual children, it is critical that parents/caregivers are provided information that is linguistically relevant.

Developmental milestones and checklists may not align with the path of neurodivergent children. ASHA stresses an individualized approach to determining how and if there are desired supports and services. Collaboration with parents/caregivers is critical. Regardless of any milestone checklist, ASHA’s long-standing advice to parents/caregivers is for them to trust their own instincts. Parents know their child best. There is no downside to their seeking an evaluation from a certified speech-language pathologist if they are concerned about their child’s speech, language, or other developmental skills. An evaluation will result in one of two outcomes, both positive: (1) It will reduce—or eliminate completely—a caregiver’s uncertainty and worry if no evidence of a problem is found or (2) if a child is found to have a delay or disorder, it will set families on an actionable path to professional help.

The importance of seeking help early cannot be overstated. Eighty percent of brain development occurs between birth and age 3 years, a period when the brain is flexible. Intervention services provided during this time will yield the maximum benefit. Seeking help at any age is strongly encouraged and can make a positive difference. However, chances for the greatest strides are optimal before the age of 3 years. Also, young children are much more likely to qualify for services for free or at reduced cost through public early intervention programs prior to age 3.  

Will these changes impact how children qualify for services?

In ASHA meetings with the CDC and AAP, the groups clarified that the revisions are NOT intended to impact how or if children qualify for services. Both stated that materials for tracking developmental milestones are not developmental screening tools, nor are they standardized or criterion reference assessment tools. They said that they are communication tools that aim to promote developmental monitoring; encourage conversations between parents, doctors, and early childhood providers about child development; and increase the number of developmental screenings that are conducted. According to them, the milestone checklists are just one small part of what is recommended for developmental surveillance during early childhood. That said, ASHA will be monitoring for any impact on early intervention referrals or eligibility for services.

What do you recommend for parents/caregivers, especially as they may be presented with conflicting information?

ASHA understands that families want clear information. Milestones provide guidance about the development and sequences of skills. Every child develops at their own rate. This is why the milestones on ASHA’s website are presented as a range. Again, ASHA encourages parents/caregivers to trust their instincts and seek an evaluation (these evaluations are available for free through public early intervention programs) if they have concerns. A physician’s referral is not needed: Families can directly contact their local agency (see this list by state) or their neighborhood school to be connected with help (even if their child is not yet enrolled in school). 

How are children evaluated for speech and language disorders? Is this based on not meeting published milestones?

Not at all. Clinicians select the most appropriate method(s) and measure(s) to use for a particular child based on their age; language profile; severity of suspected communication disorder; and factors related to language functioning (e.g., hearing loss and cognitive functioning). Clinicians may utilize assessment methods and measures based on the influence of a child’s cultural background and family’s values. The results from using standardized tests and informal assessment tools, observation, reported concerns, and developmental history help speech-language pathologists determine who needs services.

When did ASHA last review and update How Does Your Child Hear and Talk?

ASHA last updated this resource in 2015. The Association plans to review this resource in 2022 and, if needed, update the developmental milestones included in the resource, based on the results of that review. This work will involve considering any new research between 2015 and the present, including but not limited to what AAP and CDC used in their work on the checklists in Learn the Signs. Act Early.

How are ASHA-published milestones developed?

ASHA-published milestones are research-based and are periodically reviewed and updated as needed. Current published milestones (through ASHA’s How Does Your Child Hear and Talk? series) were updated by ASHA staff in 2015 to help caregivers learn about the sequence of 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 findings from published data (a list is available on ASHA’s website).

Does ASHA’s publishing of milestones represent an endorsement of them or an official ASHA position?

These published milestones are by-products of careful review of available research coupled with the expertise of speech-language pathologists. Ultimately, published milestones are guideposts. What determines the need for services is evaluation by speech-language pathologists—not milestones.