This year, Speech Pathologists, parents, and other professionals have taken to social media with their concerns about the recent changes made to the CDC Developmental Milestones. In this interview with developmental pediatrician, Dr. Cheryl Tierney explains what these changes really mean.
CDC Changes to Developmental Milestones
When discussing the CDC Developmental Milestones, it is important to understand what was actually changed and why. Several years ago, prior to COVID, professionals were tasked with projects to examine current research literature and adapt milestone surveillance as needed. Surveillance is an important word here as it is much different than screening. Surveillance is the questions asked and observations made during child well-checks to assess development. Surveillance, combined with exams, screening, and parental concern work together to create a need for referrals and diagnosis. The changes made with the CDC were to create clear, concrete language and timelines to take the guess work and ambiguity from pediatricians. These new Developmental Milestones Surveillance guides pediatricians with skills measured at 75% where they were previously 50%. This allows less children to slip through the cracks and more children to be referred with evidence of delay.
Motor Milestones in Babies
It’s important to note that the Milestone list was not changed, there was no removal of any skills from any milestone list, only that of the developmental surveillance. Many parents and professionals were concerned about the removal of crawling. Dr. Cheryl Tierney discusses it as a link to delays. There are no delays or disorders directly linked to late presentation or lack of crawling as opposed to other milestones. Additionally, walking was moved from 12 months to 18 months. Does this mean pediatricians will wait for intervention or referral until 18 months. Definitely not. These new surveillance guidance will actually help pediatricians know that they are surveilling the skill and that they should be noting concerns and referring around 15 months if there are no signs of walking or related skills because 75% of children are walking by 18 months.
Expressive Language Development
ASHA was not involved in the changes made to language milestones at the CDC, because of this, speech pathologists were concerned about the low bar set for language skills. Moving the milestone from pointing to two body parts, blowing a kiss, and shaking head, yes and no from 12 months to 24 months, seems worrisome. Dr. Cheryl Tierney shares my concern but notes for parents and professionals that this is still surveillance and not the concrete milestone expectation. Parents with concerns should speak up right away and not wait until well-checks if they have worries about their child’s development.
As professionals, we are always looking for new research and evolution in the field. The goal behind these changes was to provide more clear guidance for pediatricians and hopefully see fewer children slip through these cracks. As professionals voice their concerns, it is proof that more research and more literature is needed so we can continue to update and make the needed changes. If you are a parent with concerns about your child’s development, please do not wait, speak up because that is the most important tool you have.
Dr. Cheryl Tierney on the Turn Autism Around Podcast
Cheryl Tierney-Aves, MD, MPH is a Board-Certified behavior and developmental pediatrician who has been in practice since 2002. She is a native of Brooklyn, New York, and completed medical school at Tufts University in Boston. Her pediatric residency was at Levine Children’s Hospital at Carolinas Medical Center in Charlotte, North Carolina. She completed Fellowships in Health Services Research, where she received her MPH at Harvard School of Public Health as well as Behavior and Developmental Pediatrics in 2002. After 8 years on faculty at Tuft’s Baystate Children’s Hospital, she was recruited to Penn State Children’s Hospital in 2010. Dr. Tierney-Aves is a Professor of Pediatrics in the Department of Developmental Medicine. She is an active member of The Society for Developmental and Behavioral Pediatrics (SDBP) including its Advocacy Committee. Dr. Tierney is the President and founder of the ABA in PA Initiative, which is a grassroots advocacy group whose mission is to improve access and quality of ABA services in Pennsylvania. Her practice specializes in speech and language disorders to include autism and childhood apraxia of speech as well as pediatric behavioral sleep disorders.
- What does the recent change to the CDC Developmental Milestones mean?
- Who was involved in the research and change that prompted the update to the CDC Developmental Milestones?
- What is the difference between surveillance and screening?
- What pieces go into a well-check visit that lead to a referral?
- Are COVID restrictions leading to widespread delays in milestones?
- What changes were made to Motor Milestones?
- What changes were made to Language Milestones?
- Why parent concern and speaking up is important.
- Sign up for a free workshop online for parents & professionals
- No More Time Out Mini Course
- Diagnosing Autism: An Interview with Developmental Pediatrician Dr. Cheryl Tierney
- Diagnosing Autism During COVID19 Pandemic | Interview with Dr. Catherine Lord
- Hyperlexia in Children: Early Signs, Diagnosis and Treatments
- How to Recognize Early Signs of Autism in Toddlers Using MCHAT
- Is Lack of Pointing a Sign of Autism?
- Speech Delay vs Autism: Recognize the Signs to Delayed Speech in Children
- Evidence-Informed Milestones for Developmental Surveillance Tools | Pediatrics
- @DocMcCafferty Tweet
- Molly Roam, SLP: @eatplaysay
- CDC Milestones Are Intended as Tool, Not Screening, Agency Officials Clarify
Dr. Cheryl Tierney – Turn Autism Around Podcast Transcript
Transcript for Podcast Episode: 173
Dr. Cheryl Tierney : Explaining the New CDC Milestones
Hosted by: Dr. Mary Barbera
Guest: Dr. Cheryl Tierney
Mary: You're listening to the Turn Autism Around podcast, episode number one hundred and seventy three. Today, I have a friend of mine on the show, Dr. Cheryl Tierney, Avis, who is a developmental pediatrician at the Hershey Medical Center. And we are talking all about the new CDC milestones, which is all outlined in this very dense paper that was published in the journal Pediatrics in March of Twenty Twenty Two. So we are talking all about the CDC milestones, the debate and discussion around some of the milestones potentially being too low. We're talking about the positives of the new milestones. And this is a great episode for parents, as well as for professionals, as well as for health care practitioners and pediatricians to learn about why it's important to do surveillance and also add that to the screening and to diagnosis when appropriate. So let's get to this really important interview with Dr. Cheryl Tierney.
Welcome to the Turn Autism Around podcast for both parents and professionals in the autism world who want to turn things around, be less stressed and lead happier lives. And now your host. Autism mom, behavior analyst, and bestselling author, Dr. Mary Barbera.
Mary: Thank you so much. I'm going to call you, Cheryl, since you told me to call you Cheryl last time. Thank you so much for joining us today.
Dr. Tierney: Excellent. Thank you so much for having me.
Mary: Yeah. So we've been friends for, I think, over a decade now, and you are my go to person for developmental pediatrician questions. And so today we are going to talk all about the new CDC milestones and a paper that was written. And I know you were on podcast one 14 where we talked to all about a lot of different things, like your background as a developmental pediatrician and a praxis and sleep disorders and just all kinds of gold in that episode. So we're going to link that one on the show notes. But can you just briefly tell our listeners who you are in case they're just joining us for the first time?
Dr. Tierney: Yeah, thank you so much. So, yeah, we know each other almost 12 years. OK, yeah, so. So I am a professor of pediatrics and a board certified behavior and developmental pediatrician, and I'm on faculty at Penn State Hershey Children's Hospital. So that's my professional title. I'm also a mother of three of my own and two step children, and I have been in Hershey, Pennsylvania, now going on 12 years, and I'm really excited to be here today to talk to you about this topic. Ah, the first a little nervous about this topic, but I'm really excited now that some time has passed. We've had some time to reflect and think about it and see what's unfolded. So this is going to be, I think, a great podcast.
An Update in CDC Milestone Developmental Surveillance
Mary: Yeah, awesome. So back in, I think it was late December. Early January, a paper was accepted for publication and it was available online. And so I started hearing about the CDC milestones. I had no idea was happening, started hearing about that through Instagram, Twitter, Facebook posts and mostly from speech pathologists who were not happy about some of the changes in the guidelines. And some parents were saying, Well, this is just because of COVID and kids are more delayed. So they changed the guidelines, which is not true, which is we're going to dispel that myth. But anyway, it was related to this paper that is called evidence informed milestones for developmental surveillance tools, and it is published in the March issue of pediatrics, which is very reputable journal. I'm sure you would agree, and this process started back in 2019, so it was not related to COVID. So what can you tell our listeners about just generally about the article and the changes?
Dr. Tierney: Yeah, so this is great, so we should start from the beginning. Right? So basically, we should understand that the lead author, Jennifer Zoopler, she's really a wonderful person, right? So she is a a developmental pediatrician. She is a person interested in advocacy for children with disabilities. OK. And she and her colleagues were charged with this task of maybe updating these guidelines for surveillance of children with disabilities to try to identify so that we can try to identify more kids. OK. It was back. This whole thing started before COVID, and they designed this research project to look at the literature and see what published literature is out there on developmental milestones. What should children be doing at different ages? So they did. They searched the literature and they convened a working group of different professionals, and they designed this project. And so as a result of searching the literature, looking at the research and trying to determine what the new guidelines should look like for surveillance, they came up with these recommendations. And then...
Mary: They were. Also they were looking at the 2004 CDC Act Early.
Dr. Tierney: There were guidelines that were published and they were old, right?
Mary: 2004, that was the first time. So and I didn't realize until I read the article is that the American Academy of Pediatrics funded the Act Early in coordination with the CDC to publish these guidelines back in 2004, when there really wasn't anything. I know I was involved because Lucas was diagnosed in 1999. I was involved actually in the First Signs Project, which was before the CDC Act Early website. So in my book Turn Autism Around, especially in Chapter two, where I talk about potential signs of autism. Talk about lack of pointing and response to name and speech delays. And I link to the CDC website. Thank goodness I linked to the website because now the guidelines, the milestones had to have changed.
Dr. Tierney: But yeah, it's the same link.
Mary: They were doing research to look at these guidelines and say, are they evidence based? Are they clear or are they subjective? I know after reading the article, I'd say, you know, let's let's talk about like the positive changes that were made. I can think of a couple. Maybe you want to start?
Dr. Tierney: Yeah, yeah. So like any research, right? So there's always no research is perfect, right? Of course, that's just the fact that research is never going to be perfect. But given that they were charged with doing updates to guidelines that were very old, they decided to do a literature search and they had certain criteria. And the one thing we look at when we look at published literature is, do they tell us what their methods are for how they went about looking at the criteria they used for how they were going to include which research they were going to include and what research they weren't going to include? And I think this article did a good job. They told us this is how we the search terms we used. This is what met criteria for what was going to go into this article, this is what was going to go into our review of the literature. This is the criteria we used for how we picked which articles met that criteria. So I think that was a strength of this article of this research. They said we convened this group. We searched the literature. We used these articles that met this criteria. So that would be a strength. You said what would be a strength that was a strength? Yeah. Do I think it was perfect? You know, we can talk about things that maybe were were limitations, maybe a little bit at the same time. Maybe it wasn't as comprehensive and there might have been areas for improvement, but did they tell us what they did? Yes, they told us what they did, and it's very transparent to what they did. Yeah.
Subject Matter Experts Involved in the CDC Project
Mary: And the eight subject matter experts were in different fields of child development, so they had developmental, behavioral, neurodevelopmental, and pediatricians, child and developmental psychologist, professor of special education, early intervention. And you know, one of the issues, a lot of these are language based. And so the SLP, the speech language pathology community, ASHA is there. They're a big organization, and they have released a statement saying that they would have liked to have a seat at that table. And I think that would have been a good addition. Yeah. So we could link that ASHA in the show notes as well, we could.
Dr. Tierney: If you want, we can. We can pause and talk a minute about what happened there. So, yeah, for sure that there wasn't a, you know, in retrospect, should there have been more people at the table to collaborate with? I think you can make an argument that there's always going to be people that feel that they were left out at the table, right? Can you always include everybody? I think, could you? Of course, after the fact, it's easy after the fact when people criticize to say, Yeah, that would may have been a nice addition and we should have. But for certain that there was a collaboration afterwards with ASHA, Asher did sit down with the CDC and the authors afterwards to take a look, and I know that that meeting was a positive experience both for ASHA and for the CDC, but that did go on afterwards. What will come of that? More down the road? I don't know. But there definitely was. There were meetings that took place afterwards that I'm aware of. Mm hmm.
Mary: Right. And the other thing is this is surveillance and surveillance is different than screening is different than diagnosis.
Dr. Tierney: Yes.
Mary: You want to touch on that?
Surveillance Vs. Screening
Dr. Tierney: Yeah. Yeah, for sure. I think that that's something that's important for people to know about this. So as we're updating, like, why is this important? Well, in the past, I know that some of the criticisms of the surveillance that was happening, why did we even update this? Well, we know that we were missing a lot of children that a lot of kids were being missed. And the goal of this of the authors and of the medical community at large was that there was too much wait and see. There was a lot of and I'm sure you hear this a lot. My pediatrician said, Let's just watch this and see why was that happening? That was happening because the old guidelines were at what we call the 50th percentile, right? So 50 percent of kids should have the skill, but 50 percent of kids, it was still normal not to have that. That milestone did not meet that milestone. So if you would refer every child who was not meeting that milestone, you would worry a lot of parents where it was still normal and pediatrician, some pediatricians were very proactive. You're not meeting that milestone. Refer, refer, refer. Some pediatricians very aggressive. Some pediatricians much more laid back. They really didn't want to worry a lot of parents. Maybe they'd say, Listen, let's just see if I buy the next visit. Your child's not meeting that milestone. I'll refer you then right? And a lot of kids who had real problems with their development would not would be waiting and seeing when they should have been referred by this reanalysis by this these new guidelines. Now this allowed us that what they chose to do is move the recommendations to what we call the seventy fifth percentile. What that means is that if you miss this milestone, this survey, the surveillance at this milestone, what that's telling us is that 75 percent of children should be doing this. And the recommendation now with these new guidelines is that you should refer. It is not a maybe it is a you should refer. And that takes some of the ambiguity away now. And the pediatricians now have much clearer recommendations for what to do. And there be a whole lot less wait and see. And the wording is much clearer. So that's one of the things this paper really stresses is moving the recommendation to 75th percentile and taking away that wishy washy language of may or might so that it's much clearer what to do.
Mary: Right? And and also in the same vein, I think the wording got stronger. So it went from the old checklist where, you know, a child may begin to transfer objects from hand to hand to the child will or the child should be transferring objects from one hand to another. That language it's it's clearer, it's more direct and because 75 percent of children do. And if you don't, you need to go the step father. But so this whole thing we're talking about is surveillance. It's aware of the milestones, which I'm a huge fan of, even for a child diagnosed with autism. I'm a big fan of knowing what milestones come first. You know, you can't work on eating with utensils. Well, you can. But I would prefer you work on the 18 month skills the eating with a spoon, the drinking from a straw, drinking from an open cup. Eating finger foods. If you can't do that, you really shouldn't be working on the higher level skills, like using a fork and a knife. And so I'm constantly in my book and my work and all my video blogs talking about starting with where there's the deficit, where's the biggest deficit. Before you go adding higher level skills?
Dr. Tierney: Yeah, we call that the foundational skills. So and I was saying the same thing. So maybe just to also say because I think I didn't answer, but you brought it up again, is the difference between surveillance, right? What surveillance is and. And that in the past we surveillance is where we check these skills at every single well-child visit. So where we survey or we check whether your child is meeting these or has these skills by asking questions at every well-child visit in the past. Your pediatrician didn't do that or may not have done that at every well, child visit. In particular, there were certain well-child visits that were left out of surveillance and surveillance. These this paper focuses on surveillance being one aspect of a comprehensive developmental assessment by your pediatrician, history and asking you parental concerns is one. Surveillance is another, and your exam, so there is a lot that goes into determining whether your child should be referred for an evaluation. And that is important to note, because I know that in the social media comments and the online comments that have been made, there has been some criticism of these surveillance milestones that have been identified as the things that we are paying attention to. Yeah, but it's only one piece of a comprehensive assessment of your child's overall well-being, development and concern. So if you as a parent, go to your pediatrician and say, I know maybe that they're meeting these milestones or they're not meeting these milestones, but I'm still concerned that's still an indication for it to be referred. So I want to make sure I stress what, Mary, what you're saying it right? Because I've been asked these questions. What about the child who may have accelerated development in some areas? They may have below expectations in social skills, but accelerated letter identification or number identification? So they may seem advanced in some areas and behind in others. What do you do in that situation? Well, that may be a concern that you have and should be referred. So there is an unevenness to some children's development that might raise a concern. So we don't want to discount parental concern.
Mary: And so screening and correct me if I'm wrong. But the American Academy of Pediatrics does still and has for many years recommended the use of the M-CHATT at the 18 month visit and the 24 months. And these all of this surveillance is not about just autism, it's about catching kids with developmental like physical development issues and genetic issues and motor cognitive.
Dr. Tierney: Speech, just language and speech, right? Anything. Right? Of course, there are other things, right?
Mary: And that like a four month old or a six month old, like, what should they be doing? Should that be rolling over, should they be pulling up? And. And so this isn't all about autism, but the M-CHATT is all about autism and that is screaming. And I do know people who say their kids passed the M-CHATT and still had autism. Again, it's not foolproof. You know, I had an interview with an SLP who has a child on the spectrum and the pediatrician. This is in my book and somewhere. And it said, I think it's in Chapter two under pointing, which I've done a video blog and all kinds of work on pointing. But the pediatrician said, Oh, if he points, he's not autistic. It's like, that's not true. And so pointing is still on the developmental milestones for the surveillance. It's still on screening for the. And in my practice, like what I see from online participants and even just from parents that I know that I have no concerns about autism actually book Agent, you know, emailed me when I as I was writing my book and she has a she has a two year old and she's like, You know, I just that the well, visit and they were doing this M-CHATT. And, you know, it's like, I know you're writing about that. And so this isn't so screening is another important tool that is still in place, right?
Dr. Tierney: Yes. So the M-CHATT is a screening tool. What we're talking about today is surveillance and surveillance is asking you the questions, is your child reading this at those asking you those questions, whereas the M-CHATT is actually a screening tool, an actual tool. And so. Absolutely. And I like to describe it like I did a little bit like Swiss cheese, right? The layers, right? So each thing is designed to catch more, catch more, catch more so and nothing is 100 percent, you know, we wish it was. We wish that everything but you, we first survey, then we ask concerns, then we do our exam and then we add a a screening tool and we continue to add these layers to try to catch more kids. Right. We hope we do enough to catch most of them right at the end of the day. We know that a few will will slip through, right? So we we want to encourage parents to bring up their concerns to the pediatrician and by updating the surveillance. We hope that now we're raising the bar enough so that with parental concern and with our observations and with screening that we will now be able to refer, get more referrals to our early intervention providers, to the schools, to those providers that will help specialists to do the evaluation so that less children will fall through the cracks, knowing that nothing is 100 percent right.
Mary: And they did add so. This article then recommended the CDC milestone changes and that has been done. It was like all in one swoop, like the article came out and the CDC changes were in place. And I'm not sure like if ASHA responds and if tweaks could be made or if something was cited incorrectly, maybe they're, you know, it's a dynamic website. I'm sure that if there was enough, like if there was an error, they could change it. So, you know, we'll just have to leave it at that. But one of the really positive changes is in the past and the 2004 milestones. There was no 15 months of age and there was no 30 month of age. And those are two really critical critical times to critical, well checks that you could miss thing and miss some changes and some milestones.
Dr. Tierney: Yes. I think when I look at the overall net of what this will do, all the while child checks, now there's going to be surveillance. Although it never made sense to us why there are any well-child checks where we don't survey development, right? So now that's been rectified. We have you we can have a very academic discussion about whether or not the right milestone was identified and whether it's too high or too low. And. And I hope over time, this will spark more vigorous research into making sure that the bar was set at the right level. I hope that people now will look at this and say, Oh, I think that that milestone was not set at the proper level. Maybe there's not good published literature on this. And now we need to. This is just expert opinion that's out there. We don't have good published literature on it. It's not. So now we need to do more research in that area. That would be great. And so we can add to the body of literature. This should then move move things in a positive direction. But will this net benefit children to be identified, referred and service? Absolutely. That is, I think, something that we should celebrate rather than criticize for sure.
COVID and Developmental Delays
Mary: And I think the whole I forget. Exactly. We when when your last episode, when your first episode was aired or recorded, but, you know, since COVID to a lot of kids, you know, missed well checks, the waiting list got longer to go see the developmental pediatrician. Things turned virtual early intervention to virtual. I did a really good podcast interview with Dr. Catherine Lord, who's one of the leading researchers in the autism space, and she talked all about the issues with even evaluating kids when you're messed up or nervous. And she was doing evaluations in her backyard, and I think we did talk about tella evaluations and stuff in your in your podcast. 14. But, you know, I do think kids in general are more at risk for speech delay, social delay, separation anxiety. I mean, now they're going to preschool or daycare, and they're being dropped off with masked people, getting them out of their cars and like it, it just seems like. If you're a child that has been born, you know, and spent all of your life or all of your life from one to three or four. But then at the same time, parents could discount it. Oh, it's just COVID because he hasn't left the house, he hasn't gone to the grocery store or library circle time. And it's like, how do you answer that?
Dr. Tierney: Yeah. So hopefully kids under two are not being masked because that's not the recommendation, right? Right, right?
Mary: But they have been isolated and not gone to the grocery stores as much and not gone to daycare as much.
Dr. Tierney: Yes. So one is very young children don't need to be masked or shouldn't be put in the mask, right? So we're talking about slightly older kids. So in that particular, plus, we do know that children get a good exposure to facial expressions and speech from their parents at home and for generations before, maybe not in modern day right now. But for most of time we didn't have preschools, and the social settings like kids were raised at home with their parents. And I, when I explain this to parents, I'm like, You know, not everybody chooses. It's a choice to send their kids to preschool. They a lot of kids before age three are home with their parents, moms where I know now it's not so common that you have two working parents and parents send their kids to daycare and preschool. But that's not the case for everyone. And some parents are have a stay at home parent doesn't have to be mom, it can be a stay at home dad, but a stay at home parent or grandparent, and they they raise their children at home until they're three. So during those formative early years where the language is developing and social skills are developing early, they may not be exposed to many other children or they may just be exposed to a sibling. That's it. So I don't think it really accounts for that any kind of speech, language or social deficit. If you are seeing a speech, language or social deficit in your child, any kind of deficit in their eye contact, any kind of deficit in their non-verbal or joint attention or nonverbal skills that they're not coordinating nonverbal skills? Well, if they are not communicating with intent that is not COVID, that is from a problem in natural development that should be taken seriously. And while I'm not a big fan of masks and I am glad that rates are dropping and we are losing masks outside of the health care setting, I don't know what a the, it's what will happen. But for now, I'm excited about it. I hope people are getting vaccinated so that they don't get seriously ill with COVID, but they're getting out there now and we are going to be able to socialize our kids a little bit more. But I don't think it explains any kind of deficit in communication or concerns with non-verbal or social development. That would be my opinion on that. I hope that helps.
Mary: Yeah, yeah. And what about for kids that are four? Or do you think it would have any effect on articulation or anything? Or do you just think COVID is not really the reason for any kind of delays?
Dr. Tierney: So if you have a disability, could it exacerbate something? You know, I think the question I think comes up more in kids that have a speech disorder, is it harder to treat when you're masked, right? Because they may need to see your lips to do the intervention? I think that's more where we have our conversations in the academic setting for kids that need the visual cue, particularly with speech disorder. So you bring up a good point about the speech disorders, right for kids that maybe have articulation, phonological or apraxia, or kids that are relying on seeing your mouth like a hearing impairment. Then I think it is a struggle for those kids. And then for those, we either use clear marks or take their mask off and then we have clear. So I think it's a little bit more. The question is, if you already know that there is that condition, how do you best address it in a situation where masks are an issue? I think that's a that's a different maybe topic than what we're dealing with.
Mary: Yeah, yeah, OK. So let's get back to the CDC milestone. So there have been change. There are updated some positives. It was a multi-disciplinary, you know, eight experts. It was heavily. I think I read in the article that 80 percent of the milestones are now can be sourced to at least one or more references so that it's evidence based and not just pass down the alley. I think a nine month old should do this or an 18 month old to do that. Seventy five percent of the children will be doing this by that age, so it encourages the next referral added eight 15 months or 30 months. Got rid of just vague language like may begin to or whatever. It's more clear cut will. And then I think my after reading some social media stuff, which I can kind of go into a little bit of the social media stuff that I read. And then reading the actual article, I have a couple concerns. Sure, the old milestones in 2004 had warning signs, red flags that you should be concerned like you were talking about. And I don't think this was in there. But like obsessiveness or interest in letters and numbers before you can speak and that's called hyperLexia. I've done a lot of work on that. I can link them in the show notes, but like that is that Lucas had that. And I just was. And a lot of my clients and online participants have that ability. And then you kind of are like, No, no, he's smart. He's, you know, and it's like, that's actually a sign of potentially that it could be something more like autism. So one of the other red flags that Lucas had was regression. He lost skills that he previously had. And and it seems like those warning signs kind of left the website so like why? And is that a concern to you as a developmental pediatrician?
Motor Skill Milestone Surveillance
Dr. Tierney: Yeah, I would have liked the warning signs to stay on there. I don't I really can't comment to why they were removed, but I certainly would like anything that would alert parents or have a warning section for warning signs. But I don't think that I could tell you what the thinking was or what the mindset was for why they were removed.
Mary: Yeah. And then I am not a motor expert or physical therapist, and I haven't heard any physical therapists really discussing this. But crawling used to be in there, and I don't even know what age crawling was was in there. And then walking now has moved from like. You know, the average child, I think, walks at one Spencer was earlier than that. Lucas, my son with autism, was later was 14 months till he could walk, which was kind of on the late side. And there had been research done to show that kids on the spectrum actually do have tend to have motor delays. That wasn't previously known when Lucas was diagnosed more than two decades ago. But like, why make the walking so much later than we're used to?
Dr. Tierney: Yeah, so I've heard the discussion about this. I, too am not an expert in motor milestones, so I want to be careful not to talk in an area of development that I'm not an expert. So it may be a better question for one of the pediatric neurologists, or maybe a PMR physician. Yeah.
Mary: Somebody who is a physical therapist that works in a room or bench? Yeah. So you're as a developmental pediatrician. You're not. Ever alarmed by lack of crawling or so walking was 18 months, like,
Dr. Tierney: Yeah, so I can tell you that the range of walking I always talk about the range for walking to speak is generally between nine and 18 months that I know. So whenever I talk about this with families is, I always say the one milestone that has such a broad range that always seems so broad to be is the motor one that there is such a wide normal range for walking. So however, that doesn't mean that if your child is, you know, approaching the later and for walking that I wouldn't be referring them for intervention sooner. So if I had a child that was 15 months already and not walking, I wouldn't just reassure the parent and say it's OK up to 18 months. Don't worry about it. I wouldn't be doing that. I would be referring much earlier for intervention, but I also know that there's a small percentage of kids that are going to walk later, and it's still going to be in some of those kids. OK. Right? Yeah. But when you would make that referral would be younger than the higher end of that range, right? When it comes to crawling. That one's a little bit less. I know that there that has been a little bit more controversial and a lot of people have been concerned that it was taken off the surveillance. But that one, I understand a little bit more. I may not be able to speak so much to the walking and when the right referral age should be, because that one I definitely am not an expert in crawling one. I I feel I can understand a little more. The question that you have to ask about using it as a surveillance question. No, this is surveillance, not screening, right? Surveillance means I'm asking you whether your child does this or not. Right? And I'm using it to determine the likelihood that your child is going to have a disability. Right? So you have to look at the literature to say, if I ask you this question during my 15 minute, well-child checkup, am I using my time the most wisely, right? So in the motor questions. How likely is the lack of crawling or crawling linked to a motor disability? Not is crawling important or not important, not and not taking away crawling as a milestone? No one removes crawling from the milestone list of milestones. That's what I've seen on social media. They removed crawling as a milestone. Nobody removed, crawling at the milestone. They removed it from the questions that pediatricians are going to ask at the visit. See the difference? Yeah, because is crawling linked, whether a child crawls or not likely the right question, the right question to ask.
Mary: And I can see that like setting up, you know, those are the. And then then you get parents like, well, they kind of do an army crawl or like, I would have no idea when my boys crawl, but I know when they walked right, it really we up either. But you know, if I had a little baby, I would be more looking at sitting up and walking and pulling to stand. Those are those are bigger like milestones,
Dr. Tierney: And you want to look at the ones that are in the literature linked to having a diagnosis, something diagnosable. Yeah, right. Some neurological diagnosable condition. Yeah. True. True, right? So that's why that's why.
Language Milestone Surveillance
Mary: So I'm going to talk my biggest concern, and I think this is what the buzz is, are some of the language milestones. So there's two social media posts that we can actually link in the show notes. One is by Doc McCafferty, who you said was a developmental pediatrician. She is a really good kind of 15 part, commenting on the CDC milestones. So I think it's good for laypeople to to be able to read that so we can link that. And then there's a woman on SLP speech, language pathologist Molly Rome, who has the @EatPlaySay, and we're going to link that in the show notes to. So one of her graphics on Facebook, which I really liked, was, I personally think, the expressive language at one 15 months, 18 months, two and three years is too low. I think it was already too low, and now it's really too low. So she said. Molly Rose said by 12 months, the CDC milestone says understands no when, in actuality she says that actually they should be able to by 12 months identify common objects when labeled touch to body parts and follow one step directions and a routine.
Dr. Tierney: Yeah, yeah.
Mary: Yeah. And then, she said. By twenty four months, the CDC milestones say, points to two body parts, which was a 12 months, skilll blows a kiss and nods yes and no, and by two, they should be saying at least 50 words. Many more say two words frequently throughout the day. Some three word phrases and say personal pronouns like I, me and my. And so I think that kind of summarizes some of my thoughts. Is this, you know, why so low for these large, expressive language?
Dr. Tierney: Right? So this is where I think if you ask me my biggest concern fly now I I think if you look at the paper and I shared my thoughts with the lead author in the CDC and we've engaged in some conversation around it respectfully, because research is I want to start out by saying research is hard. These authors went about a difficult task to update milestones where the research isn't always easy to find and isn't always there in an evidence based scientific way, like there's not the perfect research to get right. And so while we may know certain things about language development, trying to use publish research studies about language is fraught with difficulty. I'll start with that. Yeah. While the speech and the ASHA and the speech language pathologists that are out there. And as somebody who practices in that space of communication, I agree that the bar was set too low. And we are at risk of missing still too many children. So I'm going to just say that because this is my area of expertize, whereas the motor is empathizes. And so I will share the concerns of the speech and language pathologist there, right? But it is going to be something that we will need to. Do more studies to publish what we know to be true. So the literature reflects. What expert opinion, what we know as experts, so that that literature can then reflected those milestones can be updated so that we can make sure that we raise the bar even further. But I'll end with. That doesn't mean that when parental concern is added to surveillance and then the referral is made and screening and testing is done, that those children will then be, of course, identified as having a concern and identified properly that way because once testing is done and once diagnostics are done, they will be picked up that way.
Mary: Right? Yeah, right. And that's, you know, you, your line of work. It's very much my line of work and both personally and professionally. And I see by the time people find you get to your office or by the time they find my book or my online courses, these kids are usually very much more delayed than on the fence between 50 words and 100 words like they're very delayed. So, you know, overall, I think adding the 15 month and 30 month, you know, revising the the the milestones was a great effort. I think they just, you know, if ASHA can continue to work for them, work with them to maybe up those those surveillance on the expressive language, I think we would get a little bit farther. But I also want to make a couple of points. You can always make a second visit, visit you to discuss development. You don't have to wait for a well-check. You can have discussions with the daycare teacher or the preschool teacher. They have checklists like there's there's things that I know are important and a part of my model, like a part of my assessment is drinking out of an open cup or drinking from a straw. It's grouping with a spoon. I mean, there's there's other things too that are important and there you can't have everything on a surveillance for a pediatrician to check at a, well, check. But if you're concerned, like Cheryl's saying, you need to speak up and say, I'm concerned, or if your child is very obsessed with letters or numbers or having, that's another warning sign that is in chapter two of my book is like extreme problem behaviors where you just can't settle the child. Extreme feeding problems, extreme sleep problems, extreme problems with going to the doctor's dentist haircuts. You know, that's not just a stubborn child. I mean, it could be, but if it's coupled with a language delay, sensory issues lack of pointing, then we need to discuss that even if it's not over our surveillance. That's not on. If you're concerned that and there's a range, like you said for walking, there's a range is a range for everything. What if you have a preemie? What if he's been isolated for two years? What if you know, the family speaks three languages and everybody's speaking different language? You know, like there's all those situations, but still, if you're concerned that still trumps everything and speak up.
Dr. Tierney: And Mary, remember the one they added a whole category of surveillance, the social emotional category didn't even exist before. So that's a big positive addition. This is not without limitations. I don't want to say this was perfect and isn't it all amazing? And it has limitations, right? But you know, this was done by humans. And whenever something is done by humans there's limitations, right? But but there's a lot of positive things that that will happen because of it. And and I definitely agree with you about if you have concerns, all the things you just said. I want to underscore those were great points that you just made. Great point.
Mary: Yeah. And you know, we can link in the show notes, blogs on pointing, response to name, hyperlexia, the M-CHATT, the ADOSS, like all of these things, your your previous episode, which is excellent and there's a lot you can do with or without a diagnosis, with or without any issue. You can, you know, listen to these blogs. I have a blog that has had over one million views, Is It Speech Delay or Autism with five steps you can take no matter what. So I want to also and I know Cheryl, you're right with me. You want to empower parents to. It's not it's not so much about do I need a diagnosis and how to get a line and, you know, just start learning more. Start being empowered that you can make a difference. You can start to help your child. I mean, I know you're you are helping your child. You can add more tools to help your child and more.
Dr. Tierney: 100 percent.
Dr. Cheryl Tierny on the Turn Autism Around Podcast
Mary: Yeah, yeah. So I know we're wrapping up with time, but I always like to end with the same question, and I don't remember what your answer was last time. I'm probably sure you don't remember either, but part of my podcast goals are not to just help the kids, but also to help the parents and professionals and medical professionals who might be listening, be happier and less stressed. So do you have any self-care tips or stress management tools that you use that you can recommend?
Dr. Tierney: Oh yeah, I don't remember. I don't recall exactly. I certainly don't recall what I said last time, but COVID has taught me that you have to have self-care. As the weather gets nicer, you have to be able to take a break and go for a walk. I have been in front of a personal, have been front of a computer for way too many hours a day and that is not good. So definitely going for a walk. I have a few like meditation apps, even on my my phone. I got an Apple Watch that has like this the standing reminder to get up and breathe. There are some good fitness ones on there, but for those that are raising, like, have challenging home lives, I do say that parents definitely need to be able to get out and get a break to go out of their home and have time for themselves in any way that you can. To the extent that you can carve out even 15 minutes for yourself small even a few times, like if you can get a few 10-15 minute breaks throughout the day, it makes a big difference. So that would be my recommendation for that.
Mary: I love that and I usually try to get outside every day, at least when it's not completely frigid.
Dr. Tierney: Yeah, yeah. This week was not a good week for that, but we had a taste of the nice weather and then it went away. So maybe next week.
Mary: Yeah, I think, you know, fresh air exercise, socializing. I like to walk with somebody if possible. So I think all of those getting away from the computer, I think, are great tips. So this is episode 173. I can't thank you enough for your time and your expertize, I think is a good podcast episode to really highlight that we are moving forward where we're constantly trying to make things better, make things simpler for pediatricians and for parents to understand when there might be delays or differences, and to get kids the help they need as early as possible. So thank you so much for your time.
Dr. Tierney: Thank you for having me.
Mary: If you're a parent or an autism professional and enjoy listening to this podcast, you have to come check out my online course and community where we take all of this material and we apply it. You'll learn life changing strategies to get your child or clients to reach their fullest potential. Join me for a free online workshop at MaryBarbera.com/workshop, where you can learn how to avoid common mistakes. You can see videos of me working with kids with and without autism. And you can learn more about joining my online course and community at a very special discount. Once again, go to MaryBarbera.com/workshop for all the details. I hope to see you there.
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