August 2022 Update
8/25/22 Update: There’s been a lot of interest in this post lately, so I thought I’d take the opportunity to move it to the top of the blog. Six months on, I find that not much has changed in my practice since these changes went into effect. In fact, I will be evaluating a 2-year-old with a history of prenatal drug exposure who is at about the 20 word stage expressively and a pair of almost 3-year-old twins who have fewer than 5 recognizable words in the next few weeks.
Notice that the families are making the referrals on the basis of delayed expressive language skills, not receptive. This is a point I stress below.
Have you changed what you’re doing and/or recommending to families based on the changes in these milestones? What are you doing differently?
The Original Post
Recently, the CDC updated their early childhood developmental milestones, with most of the changes centering around modifications of the language acquisition milestones.
Despite being grist for the rumor mill (and a lot of unnecessary consternation), I don’t think these changes are the result of the pandemic. If anything, parents being home with children for longer periods of time should have increased the opportunities for interaction between parents and young children. I think what we’re seeing is the result of exposing very young children to screens and passive, receptive language input rather than increasing the opportunities for joint attention, interaction, and opportunities to use their expressive language skills.
I think the early language milestone changes could be more evidence that the assumption that receptive language precedes expressive language development may be fundamentally flawed. I think these changes should indicate to speech-language pathologists and early childhood educators that there needs to be more focus on developing children’s expressive language skills. Keep in mind, families are asking for help with just these skills!
So, what really changed? Closer inspection of the CDC language acquisition milestones demonstrates that timelines have slightly shifted to slightly later ages (about 6 months later). The CDC moved these milestones to the point where 75% of children were meeting them – that is they moved them to the 75th percentile. They also added milestone checklists at 15 and 30 months – two ages at which we’ve learned it’s important to screen for autism spectrum disorders.
It’s important to keep in mind that, for years, we’ve taught that the range of first words is 9-18 months. Babies are just on different developmental schedules and that 9 month range represents the heterogeneity of typical development at these early stages. The CDC is now recommending that if babies haven’t begun using their first true words by around the age of 15 months, parents should talk to their pediatrician about it. Again, this really isn’t really a change, it’s just an added milestone marker point.
If the range of first words is 9-18 months, then the CDC’s recommendation that toddlers at this age have at least 3 consistent words still is right in line with what you’ve always thought you knew about typical development. They’ve now also added that toddlers should be able to follow 1-step directions without gestures at this age. I think this second milestone will be more important to care providers than parents, but I’m glad to see the CDC make this distinction between prompting levels.
The CDC left the 24-month (2 year old) milestones relatively untouched. And, here’s where I have some questions…First, why is the CDC providing examples of display questions that are used in mainstream culture, but not in other cultures’ parenting styles (i.e., pointing to pictures in a book or showing body parts when a parent asks)? The CDC no longer states that children at 2 years of age should have 50 different words expressively, but that is very much implied in their milestones. Why, you ask? Because children don’t begin combining words into 2-3 word phrases until they acquire about 50 different words expressively. That’s true for children who are typically developing as well as children who have developmental disabilities. We just don’t see children begin to combine words until they’ve acquired at least 50 different words in their expressive vocabularies.
The new milestone recommendations at 30 months are where all of the consternation originates. The CDC’s website says children at 30 months should “say about 50 words”, “say two or more words with one action word” and “say words like ‘I’ ‘me’ or ‘we.'” Again, is this really so different than what you learned? What this says is that 75% of children should be using semantic relations like agent + action (Mommy go; Me up) or entity + action (Doggie run; Kitty meow). If you don’t know what semantic relations are and you work with this population, you really should learn what they are. Here’s a link to ASHA’s summary on the topic: Click Here
The milestone recommendations at 3, 4, and 5 years of age are unchanged.
So, what should you do if you are working with very young children? First and foremost, listen to what the families are telling you. If the families say they are concerned about expressive language development, then focus your goals and recommendations on improving the child’s expressive language development. Secondly, remind parents that children learn best when they have the opportunity to interact with other people. Tell parents to limit screen time. Provide culturally responsive opportunities for children to use their expressive language skills. This may mean teaching adults to give choice between 2 or 3 objects (e.g., Do you want 1 cracker or 2 crackers; Do you want the red shirt or blue shirt?) rather than teaching adults to talk about what they are doing. You can suggest reading books to children as one way to increase the opportunities for interaction between children and adults, but be aware that reading books to children is not a universal parenting practice. Adults may be illiterate in their home language (or it may not be a written language) and illiterate in English. So, be sure to develop some strategies for teaching adults to interact with children that do no rely on mainstream culture parenting practices. Being culturally responsive means demonstrating cultural humility. That means you provide suggestions that work for the family – even if it’s not the way you would choose to go about things in your own family.
What culturally responsive strategies have you developed when working with families of very young children?